mental health case study example

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Evaluating the Efficacy of Lumateperone for MDD and Bipolar Depression With Mixed Features

Blue Light, Depression, and Bipolar Disorder

Efficacy of Modafinil for Treatment of Neurocognitive Impairment in Bipolar Disorder

Four Myths About Lamotrigine

Securing the Future of Lithium Research

An Update on Early Intervention in Psychotic Disorders

2 Commerce Drive Cranbury, NJ 08512

609-716-7777

153 Case Studies: Real Stories Of People Overcoming Struggles of Mental Health

At Tracking Happiness, we’re dedicated to helping others around the world overcome struggles of mental health.

In 2022, we published a survey of 5,521 respondents and found:

• 88% of our respondents experienced mental health issues in the past year.
• 25% of people don’t feel comfortable sharing their struggles with anyone, not even their closest friends.

In order to break the stigma that surrounds mental health struggles, we’re looking to share your stories.

Overcoming struggles

They say that everyone you meet is engaged in a great struggle. No matter how well someone manages to hide it, there’s always something to overcome, a struggle to deal with, an obstacle to climb.

And when someone is engaged in a struggle, that person is looking for others to join him. Because we, as human beings, don’t thrive when we feel alone in facing a struggle.

Let’s throw rocks together

Overcoming your struggles is like defeating an angry giant. You try to throw rocks at it, but how much damage is one little rock gonna do?

Tracking Happiness can become your partner in facing this giant. We are on a mission to share all your stories of overcoming mental health struggles. By doing so, we want to help inspire you to overcome the things that you’re struggling with, while also breaking the stigma of mental health.

Which explains the phrase: “Let’s throw rocks together”.

Let’s throw rocks together, and become better at overcoming our struggles collectively. If you’re interested in becoming a part of this and sharing your story, click this link!

Case studies

May 28, 2024

Cognitive Reframing and Mindfulness Helped Me Overcome Depression and Suicidal Ideation

“After exploring ways to end my life, I resolved to slash my wrist. I retrieved a steak knife from the kitchen and pressed it against my skin. Yet, an unexpected sensation washed over me—a profound sense of peace, love, and joy.”

Struggled with: Depression Suicidal

Helped by: Meditation Mindfulness Self-improvement

May 21, 2024

Learning To Live With Postpartum Depression (PPD) Through Self-Acceptance and Coaching

“I absolutely did not want to talk to anyone about this. I found it easier to tell a stranger about my struggles because I knew I would not see them again. I felt that telling family or friends made my struggle real. I felt that they would now be able to hold me accountable.”

Struggled with: Postpartum depression

Helped by: Self-acceptance Social support

May 14, 2024

I’m Finding Luck After Trauma and Abuse Through Mindfulness

“I never mentioned the accident to anyone until I met my future husband at 22. He was sympathetic and supportive, and helped me understand the enormity of what I had been through.I still have not talked to my siblings about it.”

Struggled with: Abuse Depression Eating disorder Suicidal

Helped by: Meditation Mindfulness Reinventing yourself

May 7, 2024

My Journey From Hitting Rock Bottom to Overcoming Abuse, Addiction, and Eating Disorder

“Then something happened. On about day 3 or 4, the group spoke and I realized that their way of thinking around food, their rituals, and their tendencies, were all the same as the things I would do. It was wild because I thought I had made these things up myself and here I was with a room full of people who did the same things.”

Struggled with: Abuse Bullying Depression Divorce Eating disorder PTSD

Helped by: Self-Care Social support Therapy Treatment

May 2, 2024

How Yoga Became My Lifeline in Navigating Depression and Building Self-Love

“My relationship with myself was pretty broken and I had no self-belief, I had low self-esteem and I resented my family. It was through yoga that I found the truest feeling of comfort, self-compassion, and courage to move forward, grow as a person, and fall back in love with myself and life again.”

Struggled with: Depression Insomnia Stress Suicidal

Helped by: Exercise Meditation Mindfulness Self-Care

April 30, 2024

Finding Clarity After an ADHD Diagnosis and Bettering Myself With CBT and Medication

“Now as I was getting older, I felt I couldn’t trust my own thoughts in the same way as before, and self-doubt would creep in. I would constantly ask myself whether my emotions and thoughts were accurate or not when reacting to social situations. As you can imagine this was a huge challenge and draining emotionally.”

Struggled with: ADHD Autism

Helped by: Medication Social support Therapy

April 25, 2024

How I’m Seeking Moments of Happiness Despite Struggling With Depression

“The diagnosis I longed for finally arrived, but it didn’t bring the expected empowerment. While it sheds light on my struggles, it also serves as a reminder that this is a part of me that won’t simply vanish. Though mental health can be managed, I know it will always leave its mark. The most challenging part is not always pinpointing why I feel the way I do.”

Struggled with: Depression Negative body image

Helped by: Medication Therapy

April 24, 2024

How Boxing and Therapy Help Me Recover My Identity After Extreme Weight Loss

“When my body changed so drastically and rapidly, it broke my sense of self-identity. About a year into my weight loss, I began to experience early dissociation, depersonalization, and dissociative amnesia. I broke into two people. Me of now and her of before.”

Struggled with: Depression Dissociative amnesia

Helped by: Exercise Self-improvement Therapy

April 18, 2024

How Therapy, Medication and Baking Help Me Navigate Depression and OCD

“I was hospitalized for my eating disorder and my depression several times throughout my college career struggling with the will to live… I was desperate to be “normal” but my brain really got in the way of that.”

Struggled with: Anxiety Depression Eating disorder OCD Suicidal

Helped by: Medication Self-improvement Therapy Treatment

April 16, 2024

How I Found My Self-Worth After Battling Chronic Pain, Anxiety and Panic Attacks

“I remember being floored with a horrible throat infection, and I was just crying. I was done suffering, I couldn’t do it anymore, I was really broken down. That was about 2 years ago now, and it shifted something in my brain. Instead of going down the drain – and keeping that negativity going – it suddenly hit me that I’m the only one responsible for how I feel.”

Struggled with: Anxiety Chronic pain Panic attacks Stress

Helped by: Medication Self-Care Self-improvement Therapy

• Bipolar Disorder
• Therapy Center
• When To See a Therapist
• Types of Therapy
• Best Online Therapy
• Best Couples Therapy
• Best Family Therapy
• Managing Stress
• Sleep and Dreaming
• Understanding Emotions
• Self-Improvement
• Healthy Relationships
• Student Resources
• Personality Types
• Guided Meditations
• Verywell Mind Insights
• 2024 Verywell Mind 25
• Mental Health in the Classroom
• Editorial Process
• Meet Our Review Board
• Crisis Support

What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Mental Health Case Study: Understanding Depression through a Real-life Example

Imagine feeling an unrelenting heaviness weighing down on your chest. Every breath becomes a struggle as a cloud of sadness engulfs your every thought. Your energy levels plummet, leaving you physically and emotionally drained. This is the reality for millions of people worldwide who suffer from depression, a complex and debilitating mental health condition.

Understanding depression is crucial in order to provide effective support and treatment for those affected. While textbooks and research papers provide valuable insights, sometimes the best way to truly comprehend the depths of this condition is through real-life case studies. These stories bring depression to life, shedding light on its impact on individuals and society as a whole.

In this article, we will delve into the world of mental health case studies, using a real-life example to explore the intricacies of depression. We will examine the symptoms, prevalence, and consequences of this all-encompassing condition. Furthermore, we will discuss the significance of case studies in mental health research, including their ability to provide detailed information about individual experiences and contribute to the development of treatment strategies.

Through an in-depth analysis of a selected case study, we will gain insight into the journey of an individual facing depression. We will explore their background, symptoms, and initial diagnosis. Additionally, we will examine the various treatment options available and assess the effectiveness of the chosen approach.

By delving into this real-life example, we will not only gain a better understanding of depression as a mental health condition, but we will also uncover valuable lessons that can aid in the treatment and support of those who are affected. So, let us embark on this enlightening journey, using the power of case studies to bring understanding and empathy to those who need it most.

Understanding Depression

Depression is a complex and multifaceted mental health condition that affects millions of people worldwide. To comprehend the impact of depression, it is essential to explore its defining characteristics, prevalence, and consequences on individuals and society as a whole.

Defining depression and its symptoms

Depression is more than just feeling sad or experiencing a low mood. It is a serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities that were once enjoyable. Individuals with depression often experience a range of symptoms that can significantly impact their daily lives. These symptoms include:

1. Persistent feelings of sadness or emptiness. 2. Fatigue and decreased energy levels. 3. Significant changes in appetite and weight. 4. Difficulty concentrating or making decisions. 5. Insomnia or excessive sleep. 6. feelings of guilt, worthlessness, or hopelessness. 7. Loss of interest or pleasure in activities.

Exploring the prevalence of depression worldwide

Depression knows no boundaries and affects individuals from all walks of life. According to the World Health Organization (WHO), an estimated 264 million people globally suffer from depression. This makes depression one of the most common mental health conditions worldwide. Additionally, the WHO highlights that depression is more prevalent among females than males.

The impact of depression is not limited to individuals alone. It also has significant social and economic consequences. Depression can lead to impaired productivity, increased healthcare costs, and strain on relationships, contributing to a significant burden on families, communities, and society at large.

The impact of depression on individuals and society

Depression can have a profound and debilitating impact on individuals’ lives, affecting their physical, emotional, and social well-being. The persistent sadness and loss of interest can lead to difficulties in maintaining relationships, pursuing education or careers, and engaging in daily activities. Furthermore, depression increases the risk of developing other mental health conditions, such as anxiety disorders or substance abuse.

On a societal level, depression poses numerous challenges. The economic burden of depression is significant, with costs associated with treatment, reduced productivity, and premature death. Moreover, the social stigma surrounding mental health can impede individuals from seeking help and accessing appropriate support systems.

Understanding the prevalence and consequences of depression is crucial for policymakers, healthcare professionals, and individuals alike. By recognizing the significant impact depression has on individuals and society, appropriate resources and interventions can be developed to mitigate its effects and improve the overall well-being of those affected.

The Significance of Case Studies in Mental Health Research

Case studies play a vital role in mental health research, providing valuable insights into individual experiences and contributing to the development of effective treatment strategies. Let us explore why case studies are considered invaluable in understanding and addressing mental health conditions.

Why case studies are valuable in mental health research

Case studies offer a unique opportunity to examine mental health conditions within the real-life context of individuals. Unlike large-scale studies that focus on statistical data, case studies provide a detailed examination of specific cases, allowing researchers to delve into the complexities of a particular condition or treatment approach. This micro-level analysis helps researchers gain a deeper understanding of the nuances and intricacies involved.

The role of case studies in providing detailed information about individual experiences

Through case studies, researchers can capture rich narratives and delve into the lived experiences of individuals facing mental health challenges. These stories help to humanize the condition and provide valuable insights that go beyond a list of symptoms or diagnostic criteria. By understanding the unique experiences, thoughts, and emotions of individuals, researchers can develop a more comprehensive understanding of mental health conditions and tailor interventions accordingly.

How case studies contribute to the development of treatment strategies

Case studies form a vital foundation for the development of effective treatment strategies. By examining a specific case in detail, researchers can identify patterns, factors influencing treatment outcomes, and areas where intervention may be particularly effective. Moreover, case studies foster an iterative approach to treatment development—an ongoing cycle of using data and experience to refine and improve interventions.

By examining multiple case studies, researchers can identify common themes and trends, leading to the development of evidence-based guidelines and best practices. This allows healthcare professionals to provide more targeted and personalized support to individuals facing mental health conditions.

Furthermore, case studies can shed light on potential limitations or challenges in existing treatment approaches. By thoroughly analyzing different cases, researchers can identify gaps in current treatments and focus on areas that require further exploration and innovation.

In summary, case studies are a vital component of mental health research, offering detailed insights into the lived experiences of individuals with mental health conditions. They provide a rich understanding of the complexities of these conditions and contribute to the development of effective treatment strategies. By leveraging the power of case studies, researchers can move closer to improving the lives of individuals facing mental health challenges.

Examining a Real-life Case Study of Depression

In order to gain a deeper understanding of depression, let us now turn our attention to a real-life case study. By exploring the journey of an individual navigating through depression, we can gain valuable insights into the complexities and challenges associated with this mental health condition.

Introduction to the selected case study

In this case study, we will focus on Jane, a 32-year-old woman who has been struggling with depression for the past two years. Jane’s case offers a compelling narrative that highlights the various aspects of depression, including its onset, symptoms, and the treatment journey.

Background information on the individual facing depression

Before the onset of depression, Jane led a fulfilling and successful life. She had a promising career, a supportive network of friends and family, and engaged in hobbies that brought her joy. However, a series of life stressors, including a demanding job, a breakup, and the loss of a loved one, began to take a toll on her mental well-being.

Jane’s background highlights a common phenomenon – depression can affect individuals from all walks of life, irrespective of their socio-economic status, age, or external circumstances. It serves as a reminder that no one is immune to mental health challenges.

Presentation of symptoms and initial diagnosis

Jane began noticing a shift in her mood, characterized by persistent feelings of sadness and a lack of interest in activities she once enjoyed. She experienced disruptions in her sleep patterns, appetite changes, and a general sense of hopelessness. Recognizing the severity of her symptoms, Jane sought help from a mental health professional who diagnosed her with major depressive disorder.

Jane’s case exemplifies the varied and complex symptoms associated with depression. While individuals may exhibit overlapping symptoms, the intensity and manifestation of those symptoms can vary greatly, underscoring the importance of personalized and tailored treatment approaches.

By examining this real-life case study of depression, we can gain an empathetic understanding of the challenges faced by individuals experiencing this mental health condition. Through Jane’s journey, we will uncover the treatment options available for depression and analyze the effectiveness of the chosen approach. The case study will allow us to explore the nuances of depression and provide valuable insights into the treatment landscape for this prevalent mental health condition.

The Treatment Journey

When it comes to treating depression, there are various options available, ranging from therapy to medication. In this section, we will provide an overview of the treatment options for depression and analyze the treatment plan implemented in the real-life case study.

Overview of the treatment options available for depression

Treatment for depression typically involves a combination of approaches tailored to the individual’s needs. The two primary treatment modalities for depression are psychotherapy (talk therapy) and medication. Psychotherapy aims to help individuals explore their thoughts, emotions, and behaviors, while medication can help alleviate symptoms by restoring chemical imbalances in the brain.

Common forms of psychotherapy used in the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and psychodynamic therapy. These therapeutic approaches focus on addressing negative thought patterns, improving relationship dynamics, and gaining insight into underlying psychological factors contributing to depression.

In cases where medication is utilized, selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed. These medications help rebalance serotonin levels in the brain, which are often disrupted in individuals with depression. Other classes of antidepressant medications, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs), may be considered in specific cases.

Exploring the treatment plan implemented in the case study

In Jane’s case, a comprehensive treatment plan was developed with the intention of addressing her specific needs and symptoms. Recognizing the severity of her depression, Jane’s healthcare team recommended a combination of talk therapy and medication.

Jane began attending weekly sessions of cognitive-behavioral therapy (CBT) with a licensed therapist. This form of therapy aimed to help Jane identify and challenge negative thought patterns, develop coping strategies, and cultivate more adaptive behaviors. The therapeutic relationship provided Jane with a safe space to explore and process her emotions, ultimately helping her regain a sense of control over her life.

In conjunction with therapy, Jane’s healthcare provider prescribed an SSRI medication to assist in managing her symptoms. The medication was carefully selected based on Jane’s specific symptoms and medical history, and regular follow-up appointments were scheduled to monitor her response to the medication and adjust the dosage if necessary.

Analyzing the effectiveness of the treatment approach

The effectiveness of treatment for depression varies from person to person, and it often requires a period of trial and adjustment to find the most suitable intervention. In Jane’s case, the combination of cognitive-behavioral therapy and medication proved to be beneficial. Over time, she reported a reduction in her depressive symptoms, an improvement in her overall mood, and increased ability to engage in activities she once enjoyed.

It is important to note that the treatment journey for depression is not always linear, and setbacks and challenges may occur along the way. Each individual responds differently to treatment, and adjustments might be necessary to optimize outcomes. Continuous communication between the individual and their healthcare team is crucial to addressing any concerns, monitoring progress, and adapting the treatment plan as needed.

By analyzing the treatment approach in the real-life case study, we gain insights into the various treatment options available for depression and how they can be tailored to meet individual needs. The combination of psychotherapy and medication offers a holistic approach, addressing both psychological and biological aspects of depression.

The Outcome and Lessons Learned

After undergoing treatment for depression, it is essential to assess the outcome and draw valuable lessons from the case study. In this section, we will discuss the progress made by the individual in the case study, examine the challenges faced during the treatment process, and identify key lessons learned.

Discussing the progress made by the individual in the case study

Throughout the treatment process, Jane experienced significant progress in managing her depression. She reported a reduction in depressive symptoms, improved mood, and a renewed sense of hope and purpose in her life. Jane’s active participation in therapy, combined with the appropriate use of medication, played a crucial role in her progress.

Furthermore, Jane’s support network of family and friends played a significant role in her recovery. Their understanding, empathy, and support provided a solid foundation for her journey towards improved mental well-being. This highlights the importance of social support in the treatment and management of depression.

Examining the challenges faced during the treatment process

Despite the progress made, Jane faced several challenges during her treatment journey. Adhering to the treatment plan consistently proved to be difficult at times, as she encountered setbacks and moments of self-doubt. Additionally, managing the side effects of the medication required careful monitoring and adjustments to find the right balance.

Moreover, the stigma associated with mental health continued to be a challenge for Jane. Overcoming societal misconceptions and seeking help required courage and resilience. The case study underscores the need for increased awareness, education, and advocacy to address the stigma surrounding mental health conditions.

Identifying the key lessons learned from the case study

The case study offers valuable lessons that can inform the treatment and support of individuals with depression:

1. Holistic Approach: The combination of psychotherapy and medication proved to be effective in addressing the psychological and biological aspects of depression. This highlights the need for a holistic and personalized treatment approach.

2. Importance of Support: Having a strong support system can significantly impact an individual’s ability to navigate through depression. Family, friends, and healthcare professionals play a vital role in providing empathy, understanding, and encouragement.

3. Individualized Treatment: Depression manifests differently in each individual, emphasizing the importance of tailoring treatment plans to meet individual needs. Personalized interventions are more likely to lead to positive outcomes.

4. Overcoming Stigma: Addressing the stigma associated with mental health conditions is crucial for individuals to seek timely help and access the support they need. Educating society about mental health is essential to create a more supportive and inclusive environment.

By drawing lessons from this real-life case study, we gain insights that can improve the understanding and treatment of depression. Recognizing the progress made, understanding the challenges faced, and implementing the lessons learned can contribute to more effective interventions and support systems for individuals facing depression.In conclusion, this article has explored the significance of mental health case studies in understanding and addressing depression, focusing on a real-life example. By delving into case studies, we gain a deeper appreciation for the complexities of depression and the profound impact it has on individuals and society.

Through our examination of the selected case study, we have learned valuable lessons about the nature of depression and its treatment. We have seen how the combination of psychotherapy and medication can provide a holistic approach, addressing both psychological and biological factors. Furthermore, the importance of social support and the role of a strong network in an individual’s recovery journey cannot be overstated.

Additionally, we have identified challenges faced during the treatment process, such as adherence to the treatment plan and managing medication side effects. These challenges highlight the need for ongoing monitoring, adjustments, and open communication between individuals and their healthcare providers.

The case study has also emphasized the impact of stigma on individuals seeking help for depression. Addressing societal misconceptions and promoting mental health awareness is essential to create a more supportive environment for those affected by depression and other mental health conditions.

Overall, this article reinforces the significance of case studies in advancing our understanding of mental health conditions and developing effective treatment strategies. Through real-life examples, we gain a more comprehensive and empathetic perspective on depression, enabling us to provide better support and care for individuals facing this mental health challenge.

As we conclude, it is crucial to emphasize the importance of continued research and exploration of mental health case studies. The more we learn from individual experiences, the better equipped we become to address the diverse needs of those affected by mental health conditions. By fostering a culture of understanding, support, and advocacy, we can strive towards a future where individuals with depression receive the care and compassion they deserve.

Similar Posts

Exploring the World of Bipolar Bingo: Understanding the Game and Its Connection to Bipolar Disorder

Imagine a world where a game of chance holds the power to bring solace and support to individuals affected by bipolar disorder. A seemingly unlikely connection, but one that exists nonetheless. Welcome to the world of…

Can Anxiety Disorders be Genetic? Exploring the Hereditary Aspects of Anxiety Disorders

Introduction to Genetic Factors in Anxiety Disorders Understanding anxiety disorders Anxiety disorders are a common mental health condition that affect millions of individuals worldwide. People with anxiety disorders experience overwhelming feelings of fear, worry, and unease…

Understanding the Abbreviations and Acronyms for Bipolar Disorder

Living with bipolar disorder can be a challenging journey. The constant rollercoaster of emotions, the highs and lows, can take a toll on a person’s mental and emotional well-being. But what if there was a way…

The Connection Between Ice Cream and Depression: Can Ice Cream Really Help?

Ice cream has long been hailed as a delightful treat, bringing joy to people of all ages. It is often associated with carefree summer days, laughter, and moments of pure bliss. But what if I told…

Understanding the Relationship Between Bipolar Disorder and PTSD

Imagine living with extreme mood swings that can range from feeling on top of the world one day to plunging into the depths of despair the next. Now add the haunting memories of a traumatic event…

The Connection Between Meth and Bipolar: Understanding the Link and Seeking Treatment

It’s a tangled web of interconnectedness – the world of mental health and substance abuse. One doesn’t often think of them as intertwined, but for those battling bipolar disorder, the link becomes all too clear. And…

• Children's mental health case studies
• Food, health and nutrition
• Mental wellbeing
• Mental health

Explore the experiences of children and families with these interdisciplinary case studies. Designed to help professionals and students explore the strengths and needs of children and their families, each case presents a detailed situation, related research, problem-solving questions and feedback for the user. Use these cases on your own or in classes and training events

Each case study:

• Explores the experiences of a child and family over time.
• Introduces theories, research and practice ideas about children's mental health.
• Shows the needs of a child at specific stages of development.
• Invites users to “try on the hat” of different specific professionals.

By completing a case study participants will:

• Examine the needs of children from an interdisciplinary perspective.
• Recognize the importance of prevention/early intervention in children’s mental health.
• Apply ecological and developmental perspectives to children’s mental health.
• Predict probable outcomes for children based on services they receive.

Case studies prompt users to practice making decisions that are:

• Research-based.
• Practice-based.
• Best to meet a child and family's needs in that moment.

Children’s mental health service delivery systems often face significant challenges.

• Services can be disconnected and hard to access.
• Stigma can prevent people from seeking help.
• Parents, teachers and other direct providers can become overwhelmed with piecing together a system of care that meets the needs of an individual child.
• Professionals can be unaware of the theories and perspectives under which others serving the same family work
• Professionals may face challenges doing interdisciplinary work.
• Limited funding promotes competition between organizations trying to serve families.

These case studies help explore life-like mental health situations and decision-making. Case studies introduce characters with history, relationships and real-life problems. They offer users the opportunity to:

• Examine all these details, as well as pertinent research.
• Make informed decisions about intervention based on the available information.

The case study also allows users to see how preventive decisions can change outcomes later on. At every step, the case content and learning format encourages users to review the research to inform their decisions.

Each case study emphasizes the need to consider a growing child within ecological, developmental, and interdisciplinary frameworks.

• Ecological approaches consider all the levels of influence on a child.
• Developmental approaches recognize that children are constantly growing and developing. They may learn some things before other things.
• Interdisciplinary perspectives recognize that the needs of children will not be met within the perspectives and theories of a single discipline.

There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

• Adolescent depression.
• School mental health.
• Rural mental health services.
• Social/emotional development.

The Brianna and Tanya case study reflects themes of:

• Infant and early childhood mental health.
• Educational disparities.
• Trauma and toxic stress.
• Financial insecurity.
• Intergenerational issues.

The case studies are designed with many audiences in mind:

Practitioners from a variety of fields. This includes social work, education, nursing, public health, mental health, and others.

Professionals in training, including those attending graduate or undergraduate classes.

The broader community.

Each case is based on the research, theories, practices and perspectives of people in all these areas. The case studies emphasize the importance of considering an interdisciplinary framework. Children’s needs cannot be met within the perspective of a single discipline.

The complex problems children face need solutions that integrate many and diverse ways of knowing. The case studies also help everyone better understand the mental health needs of children. We all have a role to play.

These case has been piloted within:

Graduate and undergraduate courses.

Discipline-specific and interdisciplinary settings.

Professional organizations.

Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

Instructors have used the case study effectively by:

• Assigning the entire case at one time as homework. This is followed by in-class discussion or a reflective writing assignment relevant to a course.
• Assigning sections of the case throughout the course. Instructors then require students to prepare for in-class discussion pertinent to that section.
• Creating writing, research or presentation assignments based on specific sections of course content.
• Focusing on a specific theme present in the case that is pertinent to the course. Instructors use this as a launching point for deeper study.
• Constructing other in-class creative experiences with the case.
• Collaborating with other instructors to hold interdisciplinary discussions about the case.

To get started with a particular case, visit the related web page and follow the instructions to register. Once you register as an instructor, you will receive information for your co-instructors, teaching assistants and students. Get more information on the following web pages.

• Brianna and Tanya: A case study about infant and early childhood mental health
• About Steven: A children’s mental health case study about depression

Cari Michaels, Extension educator

Reviewed in 2023

© 2024 Regents of the University of Minnesota. All rights reserved. The University of Minnesota is an equal opportunity educator and employer.

• Report Web Disability-Related Issue |
• Privacy Statement |
• Staff intranet

How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

Download 3 Free Positive CBT Exercises (PDF)

These detailed, science-based exercises will equip you or your clients with tools to find new pathways to reduce suffering and more effectively cope with life stressors.

Download 3 Free Positive CBT Tools Pack (PDF)

By filling out your name and email address below.

Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

World’s Largest Positive Psychology Resource

The Positive Psychology Toolkit© is a groundbreaking practitioner resource containing over 500 science-based exercises , activities, interventions, questionnaires, and assessments created by experts using the latest positive psychology research.

Updated monthly. 100% Science-based.

“The best positive psychology resource out there!” — Emiliya Zhivotovskaya , Flourishing Center CEO

The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

Share this article:

Article feedback

What our readers think.

I found this very helpful and MORE understanding. I think I will often visit this page.

Let us know your thoughts Cancel reply

Your email address will not be published.

Save my name, email, and website in this browser for the next time I comment.

Related articles

Youth Counseling: 17 Courses & Activities for Helping Teens

From a maturing body and brain to developing life skills and values, the teen years can be challenging, and mental health concerns may arise. Teens [...]

How To Plan Your Counseling Session: 6 Examples

Planning is crucial in a counseling session to ensure that time inside–and outside–therapy sessions is well spent, with the client achieving a successful outcome within [...]

Applied Positive Psychology in Therapy: Your Ultimate Guide

Without a doubt, this is an exciting time for positive psychology in therapy. Many academics and therapists now recognize the value of this fascinating, evolving [...]

Read other articles by their category

• Body & Brain (49)
• Coaching & Application (58)
• Compassion (25)
• Counseling (51)
• Emotional Intelligence (23)
• Gratitude (18)
• Grief & Bereavement (21)
• Happiness & SWB (40)
• Meaning & Values (26)
• Meditation (20)
• Mindfulness (44)
• Motivation & Goals (45)
• Optimism & Mindset (34)
• Positive CBT (30)
• Positive Communication (21)
• Positive Education (47)
• Positive Emotions (32)
• Positive Leadership (19)
• Positive Parenting (16)
• Positive Psychology (34)
• Positive Workplace (37)
• Productivity (18)
• Relationships (44)
• Resilience & Coping (38)
• Self Awareness (21)
• Self Esteem (38)
• Strengths & Virtues (32)
• Stress & Burnout Prevention (34)
• Theory & Books (46)
• Therapy Exercises (37)
• Types of Therapy (64)

Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

Cookies on the NHS England website

We’ve put some small files called cookies on your device to make our site work.

We’d also like to use analytics cookies. These send information about how our site is used to a service called Google Analytics. We use this information to improve our site.

Let us know if this is OK. We’ll use a cookie to save your choice. You can  read more about our cookies before you choose.

Change my preferences I'm OK with analytics cookies

Mental health case studies

Driving up quality in mental health care.

Mental health care across the NHS in England is changing to improve the experiences of the people who use them. In many areas, a transformation is already under way, offering people better and earlier access as well as more personalised care, whilst building partnerships which reach beyond the NHS to create integrated and innovative approaches to mental health care and support.

Find out more through our case studies and films about how mental health care across the NHS is changing and developing to better meet people’s needs.

• Children and young people (CYP)
• Community mental health
• Crisis mental health
• Early intervention in psychosis (EIP)
• Improving access to psychological therapies (IAPT)
• Perinatal mental health
• Severe mental illness (SMI)
• Staff mental health and wellbeing
• Other mental health case studies
• Archived mental health case studies

• Case report
• Open access
• Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

43k Accesses

2 Citations

1 Altmetric

Metrics details

Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 2012;9(11):e1001349. https://doi.org/10.1371/journal.pmed.1001349 . Epub 2012 Nov 27

Article   PubMed   PubMed Central   Google Scholar  

Kreppner JM, O'Connor TG, Rutter M, English and Romanian Adoptees Study Team. Can inattention/overactivity be an institutional deprivation syndrome? J Abnorm Child Psychol. 2001;29(6):513–28. PMID: 11761285

Article   CAS   PubMed   Google Scholar  

Dejong M. Some reflections on the use of psychiatric diagnosis in the looked after or “in care” child population. Clin Child Psychol Psychiatry. 2010;15(4):589–99. https://doi.org/10.1177/1359104510377705 .

Article   PubMed   Google Scholar  

Pincus HA, McQueen LE, Elinson L. Subthreshold mental disorders: Nosological and research recommendations. In: Phillips KA, First MB, Pincus HA, editors. Advancing DSM: dilemmas in psychiatric diagnosis. Washington, DC: American Psychiatric Association; 2003. p. 129–44.

Google Scholar  

Shankman SA, Lewinsohn PM, Klein DN, Small JW, Seeley JR, Altman SE. Subthreshold conditions as precursors for full syndrome disorders: a 15-year longitudinal study of multiple diagnostic classes. J Child Psychol Psychiatry. 2009;50:1485–94.

AACAP. Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. J Am Acad Child Adolesc Psychiatry. 2005;44:1206–18.

Article   Google Scholar  

dosReis S, Zito JM, Safer DJ, Soeken KL. Mental health services for youths in foster care and disabled youths. Am J Public Health. 2001;91(7):1094–9.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Breland-Noble AM, Elbogen EB, Farmer EMZ, Wagner HR, Burns BJ. Use of psychotropic medications by youths in therapeutic foster care and group homes. Psychiatr Serv. 2004;55(6):706–8.

Olfson M, Crystal S, Huang C. Trends in antipsychotic drug use by very young, privately insured children. J Am Acad Child Adolesc Psychiatry. 2010;49:13–23.

PubMed   Google Scholar  

Ercan ES, Basay BK, Basay O. Risperidone in the treatment of conduct disorder in preschool children without intellectual disability. Child Adolesc Psychiatry Ment Health. 2011;5:10.

Memarzia J, Tracy D, Giaroli G. The use of antipsychotics in preschoolers: a veto or a sensible last option? J Psychopharmacol. 2014;28(4):303–19.

Safer DJ. A comparison of risperidone-induced weight gain across the age span. J Clin Psychopharmacol. 2004;24:429–36.

Correll CU, Manu P, Olshanskiy V. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA. 2009;302:1765–73.

Kearns GL, Abdel-Rahman SM, Alander SW. Developmental pharmacology – drug disposition, action, and therapy in infants and children. N Engl J Med. 2003;349:1157–67.

Monk C, Spicer J, Champagne FA. Linking prenatal maternal adversity to developmental outcomes in infants: the role of epigenetic pathways. Dev Psychopathol. 2012;24(4):1361–76. https://doi.org/10.1017/S0954579412000764 . Review. PMID: 23062303

Cecil CA, Viding E, Fearon P, Glaser D, McCrory EJ. Disentangling the mental health impact of childhood abuse and neglect. Child Abuse Negl. 2016;63:106–19. https://doi.org/10.1016/j.chiabu.2016.11.024 . [Epub ahead of print] PMID: 27914236

Nemeroff CB. Paradise lost: the neurobiological and clinical consequences of child abuse and neglect. Neuron. 2016;89(5):892–909. https://doi.org/10.1016/j.neuron.2016.01.019 . Review. PMID: 26938439

Download references

Acknowledgements

We are also grateful to patient’s legal guardian for their support in writing this manuscript.

Availability of data and materials

Not applicable.

Author information

Authors and affiliations.

Mayo Clinic, Department of Psychiatry and Psychology, 200 1st SW, Rochester, MN, 55901, USA

Magdalena Romanowicz, Alastair J. McKean & Jennifer Vande Voort

You can also search for this author in PubMed   Google Scholar

Contributions

MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

Corresponding author

Correspondence to Magdalena Romanowicz .

Ethics declarations

Ethics approval and consent to participate, consent for publication.

Written consent was obtained from the patient’s legal guardian for publication of the patient’s details.

Competing interests

The author(s) declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

Download citation

Received : 20 December 2016

Accepted : 01 September 2017

Published : 11 September 2017

DOI : https://doi.org/10.1186/s12888-017-1492-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Polypharmacy
• Disinhibited social engagement disorder

BMC Psychiatry

ISSN: 1471-244X

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• Research article
• Open access
• Published: 01 April 2021

Three case studies of community behavioral health support from the US Department of Veterans Affairs after disasters

• Tamar Wyte-Lake   ORCID: orcid.org/0000-0001-8449-7701 1 , 2 ,
• Susan Schmitz 1 ,
• Reginald J. Kornegay 3 ,
• Felix Acevedo 4 &
• Aram Dobalian 1 , 5  

BMC Public Health volume  21 , Article number:  639 ( 2021 ) Cite this article

2374 Accesses

2 Citations

Metrics details

Community disaster resilience is comprised of a multitude of factors, including the capacity of citizens to psychologically recover. There is growing recognition of the need for public health departments to prioritize a communitywide mental health response strategy to facilitate access to behavioral health services and reduce potential psychological impacts. Due to the US Department of Veterans Affairs’ (VA) extensive experience providing trauma-informed behavioral healthcare to its Veterans, and the fact that VA Medical Centers (VAMCs) are located throughout the United States, the VA is well situated to be a key partner in local communities’ response plans. In this study we examined the role the VA can play in a community’s behavioral health response using case studies from three disasters.

This study investigated experiences of VA employees in critical emergency response positions ( N  = 17) in communities where disasters occurred between 2017 and 2019. All respondents were interviewed March–July 2019. Data were collected via semi-structured interviews exploring participants’ experiences and knowledge about VA activities provided to communities following the regional disasters. Data were analyzed using thematic and grounded theory coding methods.

Respondents underscored VA’s primary mission after a disaster was to maintain continuity of care to Veterans. The majority also described the VA supporting community recovery. Specifically, three recent events provided key examples of VA’s involvement in disaster behavioral health response. Each event showed VA’s integration into local response structures was facilitated by pre-existing emergency management and clinical relationships as well as prioritization from VA leadership to engage in humanitarian missions. The behavioral health interventions were provided by behavioral health teams integrated into disaster assistance centers and non-VA hospitals, VA mobile units deployed into the community, and VA telehealth services.

Conclusions

Recent disasters have revealed that coordinated efforts between multidisciplinary agencies can strengthen communities’ capacity to respond to mental health needs, thereby fostering resilience. Building relationships with local VAMCs can help expedite how VA can be incorporated into emergency management strategies. In considering the strengths community partners can bring to bear, a coordinated disaster mental health response would benefit from involving VA as a partner during planning.

Peer Review reports

Disaster behavioral health

The current COVID-19 pandemic, while still underway, has already demonstrated the need for psychological interventions to manage the isolation, stress, and trauma stemming from the ongoing disaster [ 1 , 2 , 3 , 4 , 5 ]. While the scale of the event is unprecedented, interest in understanding the psychological consequences of disasters is not unique to the pandemic [ 6 , 7 , 8 , 9 , 10 ]. Generally, studies exploring the impacts of disasters on behavioral health have found increases in psychological distress in the short term, with the potential for some individuals to experience long-term psychiatric disorders such as posttraumatic stress disorder, depression, and anxiety [ 6 , 7 , 8 , 9 , 10 ].

To ameliorate the potential negative health effects to impacted populations, numerous early interventions have been explored [ 7 , 11 , 12 , 13 , 14 ]. Some countries such as the Netherlands and Iceland use federally structured plans to implement disaster behavioral health interventions [ 12 , 15 ]. And countries like New Zealand have invested heavily in developing extensive mental health programs in response to large scale disaster events [ 16 , 17 ]. In the United States, federal entities strive to create resources and guidance on implementing behavioral health services after disaster, however, interventions are generally managed and delivered by state, territory, and local agencies [ 14 , 18 , 19 ]. Often, after federally declared disasters, the US Federal Government additionally provides funding through the Crisis Counseling Assistance and Training Program (CCP) to community behavioral health programs [ 8 , 13 , 20 ]. Yet the structure and content of interventions are left to the discretion of the implementing agency.

Regardless of the services provided, having a plan in place prior to a disaster can facilitate implementation [ 8 , 11 , 12 , 13 , 19 , 21 , 22 ]. Few publications detail the creation of a local disaster behavioral health response plans [ 15 , 18 , 20 ] or describe the process in which interventions were deployed following an incident [ 7 , 10 , 15 , 20 , 23 , 24 ]. Common themes arising in studies exploring disaster behavioral health plans or interventions are the need for interdisciplinary teams and interagency collaboration [ 8 , 12 , 18 , 19 , 20 ] and strong community response [ 16 ].

The United States Department of Veterans Affairs

One interagency partner often overlooked in the United States is the U.S. Department of Veterans Affairs (VA) Veterans Health Administration (VHA). Previous publications on VHA’s participation in collaborative disaster planning and preparedness efforts with local communities identified barriers to its involvement [ 25 , 26 ]. One such barrier is that the community, and sometime even VHA employees, are unaware that VHA is tasked with planning for and acting to support “national, state, and local emergency management, public health, safety and homeland security efforts” [ 9 , 27 ]. This responsibility to contribute to community efforts is called the VA’s Fourth Mission and is in addition to VHA’s duty to ensure continuity of services to veterans after a disaster.

The expertise of VHA’s 322,030 healthcare professionals and support staff who provide a range of services at its 1255 healthcare facilities spread throughout the U.S. and its territories makes VHA a valuable potential partner in disaster response [ 28 ]. In addition to inpatient and ambulatory medical care, VHA provides a variety of reintegration programs including trauma recovery and behavioral health services for Veterans and their families at its facilities and through community-based care at Vet Centers, Mobile Vet Centers, and college and university campuses [ 29 ]. How these services are applied in community response efforts has been detailed in the grey literature [ 28 , 30 , 31 , 32 ].

This study highlights the potential role of local VA facilities in supporting local behavioral health activities after a disaster, and specifically, presents three exemplars of VHA integrating into communities’ disaster behavioral health response and providing behavioral health support to non-Veterans. The three VA facilities and the events they responded to are: (1) VA Pacific Island Healthcare System (VAPIHC), which is based in Honolulu, Hawaii but provides care to Veterans throughout numerous Pacific Islands. On October 24th, 2018, Super Typhoon Yutu made direct landfall on the Mariana Islands, a US Commonwealth with a nascent established VA tele-mental health clinic on the island of Tinian. This was the strongest typhoon ever recorded to strike the area, severely damaging or destroying many buildings and much of the critical infrastructure of Tinian [ 33 ]; (2) Orlando VA Healthcare System, which serves east central Florida, and encompasses 7 counties. On June 12, 2016, a domestic terrorist attack [ 34 ], targeted hate crime, and one of the deadliest mass shootings in the U.S. occurred at a local establishment, Pulse Nightclub. In a matter of hours, 49 people were killed and 53 were wounded before law enforcement breached the building and ended the violence [ 35 ]; and (3) VA Southern Nevada HCS (VASNHCS), located in and providing care throughout Las Vegas, Nevada. On October 1, 2017, the worst mass shooting in modern history took place at the Route 91 Harvest Music Festival on the downtown Las Vegas Strip. A gunman opened fire on a crowd of more than 22,000, killing 58 people and wounding 413 [ 36 ]. These cases provide examples of interagency partnerships and the implementation of collaborative responses for communities developing their own plans to address the behavioral health needs of their citizens during disasters, including the ongoing COVID-19 pandemic.

Study design

The results presented in this paper stem from a larger study broadly examining the role of local VA facilities in responding to regional large-scale disasters. This study used qualitative interview methods to elicit study participants’ experiences during disasters impacting the U.S. between 2016 and 2018 (see Table  1 for the full list of the disasters covered in the study, the impacted US states and territories, and VA entities affiliated with the impacted areas). Findings on disaster behavioral health functions were pulled as a subset of data and analyzed. The VA Greater Los Angeles Healthcare System Institutional Review Board (Los Angeles, California USA) approved this study.

Setting and sample

The full study sample was purposively chosen to represent individuals with emergency response roles critical to coordinating VA’s local response to disasters. Emergency management personnel at various levels of the VA were the first point of contact and, when applicable, identified additional individuals with critical response roles to interview. Additional respondents were recruited independently by the project team These facilities made up the broad recruitment sample. Due to some respondents covering multiple disasters or being deployed to disasters outside their normal service region, not all entities were included in the final sample.

Data collection methods

Data were collected through semi-structured, 60-min telephone interviews between March–August 2019, using an interview guide developed for this study (see Additional file  1 ). Interviews were conducted individually with each respondent and led jointly by at least two of the authors. Interviews explored participants’ experiences and knowledge about VA activities in the community, specifically focusing on how VA networked and coordinated with non-VA community agencies. Interviews were audio-recorded, although one respondent declined to be recorded.

Analysis plan

A total of 17 individuals were interviewed. However, five interviews did not indicate collaborating with non-VA entities and were therefore not included in the analysis. Due to their involvement in multiple disasters, two respondents were interviewed twice. At completion of the interviews, this resulted in 13 interview recordings being transcribed, and one set of interview notes (due to interviewee declining to be recorded), resulting in a total of 14 interviews that were analyzed with Atlas.ti (v.7) using a grounded theory approach. In phase one of analysis, one author reviewed all 14 interviews, using inductive coding to identify emergent themes in the data, and informed by extensive conversations about project findings held by the project team at the conclusion of each interview [ 37 ]. As a product of this process, a significant emergent theme [ 37 ] was the presence of interagency partnerships implementing collaborative responses to address the behavioral health needs of local citizens during disasters. A decision was made by the project team to narrow the focused coding analyses [ 37 ] to the way local VA facilities engaged in a behavioral response within their local community, in response to their respective large-scale disaster events.

In phase two of the analysis, the initial codes identified by SS were reviewed by TWL for consistency and agreement. Codes not deemed consistent to the focus topic were dropped. Additional grounded themes were confirmed by the team and applied to the data set [ 37 ]. Consensus on final codes was achieved, and one code list was finalized. In phase three of the analysis, the final code list was applied across all relevant interviews. The final code list had a focus on behavioral health response, including behavioral health activities, method of delivery, reactions of staff, and types of impacted community populations, but also included an identification of high level themes across all disasters, including VA expertise, integrating into local, established response activities, identification of local needs, and logistical challenges. Authors TWL and SS then independently coded each interview and resolved discrepancies by consensus.

All respondents played a substantial role in VA’s activities following the respective disasters. However, only 12 participants indicated the VAMC they supported collaborated with non-VA partners during the event in question. Included disasters ranged from widespread to geographically contained; weather-related to acts of violence; and direct impact on VA facilities ranged from none to significant. Though not all respondents described intensive engagement with the community following the event, all respondents described the importance of integrating into local, established response activities. This translated into involvement in community-wide drills and planning committees and following the lead of local incident command. Respondents indicated one of the areas where the VA could provide support to the community was in disaster behavioral health relief operations.

Activities described by respondents were often centered around tasks where the VA could reduce the caseload of other community agencies by identifying Veterans obtaining services in the community and meeting their needs regardless if they were previously enrolled in VA benefits. One key activity described by several respondents included outreach into local shelters. As one respondent explained, VA staff at shelters “[distribute] fliers [that] outline that our counselors are experts in trauma, loss, and in readjustment. They also provide referrals to Veterans for a variety of services, including housing and employment. We also offered free counseling for all community members impacted .”

Identifying where shelters were established and receiving authorization to deploy VA assets to those locations required coordination with local authorities. Multiple respondents mentioned connecting with emergency management running relief efforts to describe available VA resources and detail the services available to both Veterans and the community at large. In some of the events explored in this study, the non-VA authorities were unaware of what the VA could offer while others had pre-existing relationships that allowed for more transparent understanding of how the VA could support response efforts. One respondent went on to describe how the disaster that impacted their VAMC led to additional outreach to local jurisdictions and shelter coordinating agencies (e.g., the American Red Cross) to build relationships and understanding specifically of the behavioral health services the VA could deploy, if needed and approved.

Respondents noted there were specific benefits to conducting outreach in locations where other agencies provided services to the people impacted such as shelters and Local Assistance Centers. They noted that VA staff could more easily reach Veterans to enroll them, if eligible, into VA services and offer care to those who usually used non-VA health and mental health facilities, thereby supporting local agencies by reducing potential patient loads elsewhere. Additionally, by positioning resources at a central location, VA could more readily offer community members services as an extension of their work with Veterans. One specific resource identified as useful for Veteran and community support was Mobile Vet Centers, which have the primary goal of providing social work and mental health services to Veterans. In cases where respondents mentioned this resource, they underscored that non-Veteran community members who requested services in the first days after the disaster were never turned away.

Three community profiles

Three disaster events described by respondents distinctly highlighted cases where the VA was deeply involved in the local community’s disaster behavioral health response. Each event showed VA’s integration into local response structures was facilitated by pre-existing emergency management and clinical relationships, as well as prioritization from VA leadership to engage in humanitarian missions to support the community.

Telehealth in Tinian, Mariana Islands

Prior to Super Typhoon Yutu impacting the Mariana Islands, the VA Pacific Island Healthcare System (VAPIHC) established tele-mental health services on the island of Tinian. These services were located at a non-VA owned healthcare clinic using pre-positioned VA telemedicine equipment and coordinated with the clinic director and staff. Typhoon Yutu devastated the island and led to many Tinian healthcare clinic employees losing their homes. The clinic with VA tele-mental health equipment became a temporary housing site for staff as it was undamaged by the storm. The clinic director realized that in addition to sheltering needs, employees also experienced significant trauma. However, there were limited mental health resources on the island. Once VA became aware of the need, it worked with other federal agencies to manage the logistics of implementing services that took advantage of pre-positioned VA resources.

“… it was a relationship that we had with [the US Department of Health and Human Services] (HHS) and a relationship that we had with the folks on Guam and Saipan … we have a lot of relationships going on. So, we knew that we had that telehealth equipment. We also knew that Tinian was … hit pretty hard. And that there was a lot of grief. And so I can’t say how it totally emerged, but there’s so many relationships and there’s so much communication during an emergency.”

Respondents reported it was initially challenging to identify whether VA could provide mental health services in the community and how the services would be funded. Staff at all levels of the VA worked with the Federal Emergency Management Agency (FEMA) and HHS to get official authorization as well as receive federal funding for VAPIHC to provide time limited tele-mental health interventions to clinic staff on Tinian. VAPIHC Tele-mental Health Hub coordinated with the local clinic director to inform employees about available services and utilized technology onsite to provide weekly support groups for 13 health center employees.

Director’s 50 in Orlando, Florida and the pulse nightclub shooting

The Orlando VA Healthcare System (OVAHCS) houses a unique emergency response team “The Director’s 50.” Made up of multi-disciplinary VA healthcare workers, including mental health professionals (i.e. psychologists, psychiatrists, mental health nurses), the Director’s 50 can deploy a team of up to 50 volunteers within 2 hours to areas throughout the region when authorized by the Orlando VAMC Director. As described by one respondent, the mission of the team is,

“to provide an immediate gap fill to an emergency before VA can get its assets organized and into a formal support and response role. So the team is multi-disciplinary and multi-functional with its capabilities, so that it can immediately address the needs of the emergency response until VA can formalize how it’s going to provide their support to the community.”

The Director’s 50 includes interdisciplinary clinical and service support training for all members such as triage and treatment services, mental health intervention, peer counseling, and psychological support to trauma. Through participation in community-wide exercises and drills, the Director’s 50 has built versatile capabilities and strong relationships with local emergency management agencies and area hospitals.

In response to the Pulse Nightclub Shooting, VA Central Office requested OVAHCS to deploy the Director’s 50 to provide VA resources and support the community’s response. The team activated their mass notification system to alert their nearly 100 volunteer members and quickly assembled an initial response team of about 15 clinical, mental health, and support professionals within 1 hour. Respondents noted having internal approval can speed up the process of deploying teams. In general, to distribute VA resources into the community, a federal disaster declaration is required to initiate the Robert T. Stafford Disaster Relief and Emergency Assistance Act or where the HHS Secretary has activated the National Disaster Medical System, both of which grant VA the ability to provide assistance. Therefore, respondents noted a need to balance expectations of leadership to help quickly, while also ensuring VA resources were legally allowed to be used in the response.

One thing that facilitated OVAHCS’s integration into the local response system was a pre-existing relationship with the City of Orlando’s Office of Emergency Management and the Central Florida Medical Disaster Coalition, which facilitated the Director’s 50 integration into the city’s response and allowed them to report to the victim reunification center. The team was tasked.

“to be the initial communication to the family members for those victims that actually passed away. So, 49 victims, our team was assigned to go ahead and be the initial contact to let them know that their loved ones had passed, and to begin the coordination for services, grief counseling and victim advocacy, you know, to help them prepare the initial points of piecing together their lives after being notified of such tragic events.”

Accordingly, the initial multi-disciplinary team narrowed its focus to mainly members with mental health expertise. Over the next 2 weeks, the team worked with the community, helping to manage vigils and gatherings for the public, and continuing grief counseling and mental health support for the whole community, including providing peer behavioral health support to municipal first responders. Since this act of violence targeted people who were Lesbian Gay Bisexual Transgender Queer (LGBTQ) frequenting Pulse Nightclub, not only were relatives of victims or survivors from inside the building affected, but the entire LGBTQ community felt the traumatic impact of the shooting. One respondent described the importance of providing mental health support from multiple community agencies when a disaster of this magnitude occurs,

“And they [the people who were at the shooting] truly needed a place, and this is why we were there for greater than just the 24-48 hours of initially identifying the people who was killed during the shooting, you had everyone that was inside of the club who were seeking a place where they could go and receive the care and support that they needed as well. And obviously, you know, this is something that is an endemic issue with healthcare as a whole, is the access to mental health counseling and services. So VA, as well as some other partnering mental health organizations were able to supply that need right there at the site where they were doing victim notification or victim reunification and family support. We were able to do that.”

One respondent noted a key point to remember about the Director’s 50, “they are all volunteers...And these people will go—you know, 24 hours a day, day in and day out, to execute that mission. And we have to think about team resiliency.” This included caring for team member’s well-being by rotating staff and providing and attending to the mental heath of one another. As described by one respondent,

“Because when it was all said and done, the team was very affected by what they had to do. You know, just imagine hearing—you know, overwhelming grief for every one of the 49 victims’ families that would show up. And the team took that burden on … and I will tell you, to this day, it still affects the people who went and supported that mission. And they really—those who supported that mission have a greater reverence for what we do now, as a team. So you’d never have to ask them to—whether they are going to support anything related to the Director’s 50. That comradery that’s there, they won’t let their own kind of—go into the bowels of despair like that, alone.”

Integrating into community response in Las Vegas, Nevada after the route 91 harvest festival shooting

As a large city with many national and international visitors, respondents described Las Vegas as having a very centralized emergency response structure. Relationships between VA Southern Nevada HCS (VASNHCS) and local response agencies and area hospitals were described as “tightknit” with great working relationships where organizations plan and prepare for disasters together. As one respondent put it,

“what I do know is my community. I know my community partners. I know what they have, what they don’t have, they know what I have, what I don’t have. And that’s what makes us so resilient. That’s community.”

Although located too far away from the Las Vegas Strip to actively receive injured victims when the shooting occurred at the Route 91 Harvest Music Festival, VASNHCS activated its Hospital Incident Command System so it could actively participate in the community’s response and organize efforts. A Multi-Agency Coordination Center (MACC) organized the response activities, and respondents underscored the value of both pre-existing relationships and an understanding of the county’s emergency response structure. As explained by a respondent,

“You can’t wait for your community to ask you. You have to be on the forefront and know what they need. And you only do that by knowing your community. You know, I spent probably as much time in my community as I do in my medical center. A lot of the time, it’s my own time, but again, it builds that relationship that when they’re updating their mass casualty plan, one of the people they’re calling is [me].”

This previous collaboration, as well as being present at the MACC, allowed VASNHCS to identify community needs that it could address.

As news of the shooting spread, VA leadership tasked VASNHCS with deploying staff into the community. However, it was challenging to balance the push from VA to deploy with continuing to respect established local coordination structures. VASNHCS maintained a presence within the Medical Area Surge Command of the MACC to offer resources and expertise, waiting for requests, instead of directly deploying assets outside of the established system.

In the immediate response, VASNHCS assisted with managing fatalities. It offered morgue space to the county and initiated the mass fatality plan to increase morgue capacity. This provided the county and partner hospitals space for victims until they could be processed, and families could claim them. Additionally, VASNHC offered a Psychological First Aid (PFA) team.

Initially, VASNHCS deployed their PFA team to the community’s family reunification center. The team was composed of social workers, psychologists, psychiatrists, administrators (as support staff), canteen services (for water and snacks to sustain clients and staff), and the medical center’s Chief of Staff. As the situation evolved, the MACC received requests from local agencies for psychological assistance and VASNHCS transitioned to directly integrating into area hospitals.

Three Las Vegas hospitals received the bulk of the injured or dead and recognized the need for psychological interventions with their staff. Due to their close relationships with other hospitals, one respondent explained that they were familiar with the Employee Assistance Program (EAP) at these hospitals. The respondent knew it would take time for the EAP to arrive onsite and they would most likely focus on clinical staff involved in directly treating the injured. Therefore, VASNHCS developed a three-pronged approach to complement EAP services at the receiving hospitals. Firstly, the PFA team provided what one respondent called “ trauma therapy ” to hospital staff, regardless whether they worked the night of the shooting. The assistance extended beyond clinical staff to non-clinical departments, such as environmental services/housekeeping, whose staff were also impacted through their response roles.

Respondents reported one of the reasons their response in the hospitals was so successful was that the team was multidisciplinary, allowing staff from different departments to talk to people in similar positions, which was valued by the recipients.

“So for example, we have a nurse that’s trained in trauma, psychological first aid. So they want the nurses at [the hospital with a patient surge], they want to talk to our team. They were still processing. But when we brought our nurse into the ward, they were more than willing to open up to her, because she was one of them. She was part of their tribe. So we try to match our tribe to their tribe, and that’s why we were successful.”

Secondly, the VASNHCS team worked with victims of the shooting, providing PFA and social work services. Thirdly, they integrated with family members of patients at the hospitals and provided them items that they did not otherwise have because they were visitors to Las Vegas. Examples included coordinating free transportation to and from hospitals and hotels, connecting them to local mortuary services, and providing information about how to access services when they returned home.

The PFA team ran for 24 h a day, for 7 days in those three impacted hospitals. To balance VA patient care with the community response mission, VASNHCS staff volunteered shifts outside of their normal work hours. One respondent described the overwhelming desire of VA staff to help their community.

“And while it didn’t impact our staff or our clinics, or our patients, it impacted our community. I think another thing that still amazes me to this day, was the outpour of our staff and what I mean by that is they were coming out of the woodwork to support. We had more volunteers working an eight-hour shift and then coming in [to volunteer] at five o’clock or four o’clock and working to midnight to two in the morning and not go home until four or five in the morning, and then go to work the next day, because we didn’t want to impact our patient care. And they were doing this out of their—you know, because they care. They care about the community, they care about the event, they care about the people. And then at the end of the day, you know, we had more volunteers than we had placements, because we did not want to overwhelm the health systems with all of these VA personnel.”

However, with new volunteers each shift, a key lesson learned was to have a daily team debrief. As people changed daily, a debrief provided key information and a running tally of support being provided to save time and avoid reinventing the wheel identifying contacts or systems already developed.

Another lesson was that preparedness requires ongoing maintenance. The importance of ongoing preparedness was underscored when VASNHCS realized that leading up to the shooting, they had reduced their focus on PFA training. As described by one respondent, “ We noticed that we need that continuous [psychological first aid] training, that we need continuous exercising, and it’s not an easy fit, to send a bunch of people to someone else’s hospital or an area to do that kind of service .” They also realized the first wave of personnel went into community hospitals without basic supplies they needed to provide services, including basic items such as pens, PFA guides, and informational brochures.

Three months following the shooting, the VASNHCS Emergency Manager, working with the Chief of Social Work hosted a lunch for staff who volunteered to thank them for their involvement. During that event, they realized volunteers were not only impacted by the event itself, but also by their time providing support in the community. They therefore created a forum to again gather staff who had deployed at the 6 month and 9 month marks to eat and talk about the impact of the event on the healthcare system and themselves. On the 1 year anniversary, management had a special event for the volunteers,

“we actually had people from the community that we supported coming in and they broke bread with our team and what they did was, they talked about what the impact of the VA Southern Nevada Healthcare System was going into that event, and how we helped them bridge the gap [of mental health support] that was crucial at that time, and how appreciative they were to our cause and our Clark County Office of Emergency Management gave all our staff that responded T-shirts that said Vegas Strong, because they wanted them to know that we—they appreciated the work that we did for them to support our community.”

The need for attention to the psychological well-being of individuals during and after a disaster has been well proven as disasters have been found to be associated with both short and long-term symptoms and disorders [ 6 , 7 , 8 , 9 , 10 , 38 ]. Although in some parts of the world there are federally structured plans to implement disaster behavioral health interventions, in the United States there is a patchwork system that often relies on support and resource allocation from a multitude of agencies [ 8 , 13 , 14 , 18 , 19 , 20 ]. In this study we examined the role the VA can play in a community’s disaster relief effort and highlighted the opportunity for VA to support behavioral health response focusing specifically on case studies from three disasters.

Essential to effective emergency management is an understanding of, and engagement with, available resources in a local community. This is of particular importance when considering complex individual and group needs such as behavioral health support. VA Medical Centers can be seen as challenging partners to work with because they are both a federal entity and a local healthcare facility [ 26 ]. However, in the case of Super Typhoon Yutu, the federal positioning of the VA and its connection with HHS and FEMA facilitated the deployment of VAPIHC virtual resources. The regional respondents who supported the VA disaster mission in Tinian described how preexisting relationships with federal partners facilitated authorization and funding.

Another potential challenge to incorporating the VA into response efforts is that prior to offering services, VA leadership must balance the mission of the agency with community needs, without contradicting the restrictions of the Stafford Act. In all three presented cases, VA’s behavioral health support was not formally included in a city or county response plan, and yet pre-existing relationships between key stakeholders facilitated the provision of VA behavioral health services to support identified community needs. Respondents also described participating in interagency coordinating groups, response trainings, and exercises before the disaster. These activities aided in a deeper understanding of the response structures each partner operated under and encouraged strong rapport between agencies.

Relationships between VA emergency management and local emergency management proved invaluable as VA staff understood that services should not be provided without first engaging local response coordinators. All VA facility leadership and emergency managers are required to be trained in the Incident Command System (ICS) and National Incident Management System (NIMS), which are the coordinating structures all U.S. response agencies work within [ 39 ]. As a health care provider at a national level, VHA falls within the operations section Essential Support Function (ESF) 8: Public Health and Medical Services to support the Department of Health and Human Services [ 40 ]. Local jurisdictions may also connect with VAMCs through ESF 8 representation. For example, the VA has provided significant support to communities impacted by COVID-19. As of July 8, 2020, VA provided more than 330,000 pieces of Personal Protective Equipment (PPE) in support of the Fourth Mission, as well as hand sanitizer, laundry support, test kits and testing support, and webcams for use with existing equipment to state and local facilities. In addition, VA has admitted 279 non-Veterans to VA Medical Centers because of the pandemic [ 27 ]. Much of this coordination was done through ESF 8 coordination at a local or national level.

While respondents did not go into detail about their participation in the emergency management structure, some participants described their VA’s roles within emergency operations as liaisons. Groups such as this could report to either the planning, operations, or command sections within the ICS. Group supervisors would most commonly report to the operations section chief, likely through branch directors, given that the focus of the work would be more on specialized functions as needed for tactical operations. Regardless of where they fit, their presence at emergency operations centers and command posts facilitated communication to allow for VA’s integration into incident action plans. Particularly during the response to mass casualty events in Orlando and Las Vegas, understanding the local response network and then proffering available services was essential to avoid confusion or duplication of activities. By working within the established coordination centers, VA’s efforts were effectively integrated into the greater community behavioral health response and were deployed to points of greatest need. Although a detailed understanding of the integration of VA activities into ICS structures fell outside of the scope of this work, future assessment of the integration of VA representatives into local, state, and/or regional ICS structures could help clarify roles and identify which section liaisons best support (e.g., operations, planning, logistics) [ 40 ].

VA is increasingly strengthening partnerships with agencies that provide behavioral health services to Veterans and their families who use non-VA community-based care [ 41 ]. In each case example, the primary support provided by VA to the community was the provision of behavioral health services in response to an identified need. Respondents described this as being due, in large part, to the recognition of VA’s expertise in trauma and post-trauma treatment, thereby allowing these resources to come to the forefront. While not mentioned by the respondents, an additional value that VA providers add to disaster behavioral health responses is their exposure to and understanding of the unique needs of various populations throughout their communities. In addition to ensuring care is culturally competent to the unique identity of being a Veteran, VA staff must respect the diversity of Veterans themselves. Just like the U.S. population at large, Veterans represent a range of ages, races, genders, sexual orientations, socioeconomic statuses, etc. and mental health services must be considerate of this diversity. The VA recognizes this and offers training to providers to understand and respect their patients’ unique needs [ 42 ]. Working with a variety of populations preposition VA staff to have a deeper understanding of the post-disaster needs of the wider community.

Two of the case examples described in this study especially bring to the forefront the importance of disaster behavioral health response planning and implementation teams understanding unique experiences of community members. Super Typhoon Yutu directly impacted an archipelago housing a majority Asian and/or Pacific Island population. The Pulse Nightclub shooting, while a terrorist event, was a targeted hate crime intended to inflict violence on the LGBTQ community. Disaster behavioral health interventions for these affected groups not only need to take into consideration the importance of cultural competency but also the potential of re-traumatization and distinct population mental health needs.

In the Northern Mariana Islands, while there is a mix of ethnic groups (Filipino, Chamorro, Chinese, Carolinian, Korean, Palauan, etc.), many either identify as or are categorized more broadly as Asian and/or Pacific Islanders. Although there are more than 1.4 million people who are considered Pacific Islanders living the in the U.S., there is a dearth of information on the mental health of this population [ 43 ]. Similarly, the prevalence and incidence rates of mental illness in the Mariana Islands is not well studied [ 44 ]. Some sources attribute this lack of understanding to a disproportionate underuse of mental health services [ 43 ]. However, Asian and Pacific Islanders within the U.S. and those territories affiliated with it often experience transgenerational trauma, discrimination, continued loss from colonization, historical trauma, and mental health stigma which can impact psychological wellbeing and help seeking behavior. Additionally, cultural elements (collectivism, reverence for the past, hierarchical social order, etc.) of this population are important to understand when providing behavioral health services [ 43 , 45 ]. One of the reasons respondents indicated that the VA was asked to provide assistance following Typhoon Yutu was the lack of availability of mental health services in Tinian. The established VA telehealth technology increased accessibility to behavioral practitioners from VAPIHC who most likely were experienced working with Asian and Pacific Island populations since more than 55,000 Veterans who identify as this ethnicity live in Island Areas or Hawaii [ 46 , 47 ].

The Pulse Nightclub Shooting was a terrorist driven hate crime targeting individuals who identified as LGBTQ. Members of this group often experience discrimination, stigma, and trauma throughout their lives. Discrimination and heterocentric health and mental health practices can marginalize this population and impact help seeking behavior [ 48 , 49 ]. This is of particular concern as individuals who are LGBTQ face numerous mental health disparities with a higher likelihood of experiencing depression, anxiety, substance misuse, and suicide attempts. The shooting not only targeted LGBTQ people but it also took place during Latin Pride Night meaning many of the victims and casualties were LGBTQ Latinx. The resulting psychological impacts of the Pulse Nightclub shooting on those directly impacted, people who are LGBTQ Latinx, and individuals in the wider LGBTQ community have been investigated and show experiences of trauma and impacts on perceived safety [ 50 ]. At the time of the shooting, the Orlando VAMC had established relationships with LGBTQ local mental health services and had staff knowledgeable in the needs of this community [ 51 ]. In fact, in the recent past, the VA has increased its efforts to ensure Veterans who are LGBTQ receive the highest quality patient-centered care possible [ 52 ]. Mental health services in particular have bolstered recognition of the complex needs of these Veterans [ 52 ].

All three cases demonstrate innovative ways VA can provide behavioral health support outside of their facilities, i.e., via telehealth capabilities across an ocean and into a healthcare clinic, teams of mobile units reaching directly into the community to support victims, victims’ families, and the community at large, and finally by incorporating PFA teams directly into hospitals to support staff, patients, and patients’ families. This flexibility across sites to address different needs and populations while using varying available infrastructure support, is paramount to any local jurisdiction’s ability to meet on the ground needs following a disaster. It demonstrates the variability between VAMCs and the importance of local disaster behavioral health planning teams to pre-identify resources to assess local capacity. Plans can then be developed that access and deploy the tools/skills of interdisciplinary and interagency teams. Building processes to deploy local health and mental health practitioners can lead to more rapid implementation of interventions and help ensure the diversity of the impacted community is recognized and respected. Additional studies focused on how communities develop disaster behavioral health plans could provide insight into which agencies are involved and how they collaborate. It may also be useful to assess whether and how these plans are implemented to identify best practices.

In addition to the people directly impacted by disasters, respondents underscored the importance of offering support to responders as well. There is growing recognition that health care workers are themselves front-line response workers who may be psychologically impacted when caring for others, leading to a growing emphasis on the importance of selfcare and employee wellbeing [ 39 , 40 , 41 , 42 ]. In all three case studies, behavioral health support was, at least in part, directed toward healthcare workers. In the case of Las Vegas, a respondent highlighted the advantage of having behavioral health support come from individuals who understood the culture of the population they were helping, e.g., nurses supporting nurses. Further, respondents in Las Vegas and Orlando highlighted the importance of supporting deployed behavioral health team members. They detailed actions to maintain staff well-being by having rotating shifts, encouraging peer support, and facilitating gatherings for staff to publicly thank them for their efforts and allow them to address their experiences together as a group. Understanding the needs of healthcare and behavioral health personnel and building support networks into response frameworks can help better sustain and strengthen the overall response process.

A primary limitation of this study is that interviews were conducted up to one and a half years after the disasters described, potentially impacting recall. However, multiple interviewees corroborated the information presented for each of the case studies. Another limitation is that this study focused exclusively on the experiences of VA employees fulfilling mission requirements and their description of instances where VA acted in support of the Fourth Mission. Very few of the respondents directly provided the behavioral health interventions. These perspectives could provide deeper understanding of the interventions themselves as well as the impacts they may have on practitioners. Neither community members nor coalition partners were interviewed in this study. Future research would benefit from both interviewing non-VA participants to explore additional perspectives and gain greater insight on how local jurisdictions experienced collaborating with VA representatives and exploring alternative approaches to mental health units within and outside VA to examine whether and when different approaches may be preferable.

As the largest integrated healthcare system in the United States, VA can play an important role in disaster response across the country. As recognition of VA’s expertise in behavioral health grows, particularly around trauma and post-trauma treatment, VA should be considered a strong potential partner in behavioral health responses. Local VAMC staff are part of the community in which they live and the Veterans they serve are a microcosm of the larger population of the U.S. As the respondents in this study showed, there is a deep desire by VA staff to provide support following a disaster if they are able. Anticipating potential behavioral health concerns, and having a plan to address them, can foster community disaster resilience. While these plans may be different for each jurisdiction, they can be strengthened by identifying and incorporating a range of partners. Having preexisting relationships where VA’s capabilities are known before a disaster occurs can facilitate the rapid deployment of VA resources into identified areas of community need. The case studies presented demonstrate the flexible nature of these resources. By extending knowledge about innovative ways to share behavioral health and other resources in a disaster response, communities and healthcare coalitions can be better prepared to engage collectively and rapidly mobilize essential assets to support the wellbeing of those who need it most.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Crisis Counseling Assistance and Training Program

U.S. Department of Veterans Affairs

Veterans Health Administration

VA Medical Center

VA Pacific Island Healthcare System

VA Southern Nevada HCS

Veterans Health Administration Health Care System

Veterans Integrated Service Network

Office of Emergency Management

US Department of Health and Human Services

Federal Emergency Management Agency

Lesbian Gay Bisexual Transgender Queer

Multi-Agency Coordination Center

Psychological First Aid

Employee Assistance Program

Personal Protective Equipment

Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912–20. https://doi.org/10.1016/S0140-6736(20)30460-8 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Fiorillo A, Gorwood P. The consequences of the COVID-19 pandemic on mental health and implications for clinical practice. Eur Psychiatry. 2020;63(1):e32. https://doi.org/10.1192/j.eurpsy.2020.35 .

Article   CAS   PubMed   Google Scholar  

Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic. N Engl J Med. 2020;383(6):510–2. https://doi.org/10.1056/NEJMp2008017 .

Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatr. 2020;33(2):e100213. https://doi.org/10.1136/gpsych-2020-100213 .

Article   PubMed   PubMed Central   Google Scholar  

Vigo D, Patten S, Pajer K, Krausz M, Taylor S, Rush B, et al. Mental health of communities during the COVID-19 pandemic. Can J Psychiatr. 2020. https://doi.org/10.1177/0706743720926676 .

Beaglehole B, Mulder RT, Frampton CM, Boden JM, Newton-Howes G, Bell CJ. Psychological distress and psychiatric disorder after natural disasters: systematic review and meta-analysis. Br J Psychiatry. 2018;213(6):716–22. https://doi.org/10.1192/bjp.2018.210 .

Article   PubMed   Google Scholar  

Beinecke R, Raymond A, Cisse M, Renna K, Khan S, Fuller A, et al. The mental health response to the Boston bombing: a three-year review. Int J Ment Health. 2017;46(2):89–124. https://doi.org/10.1080/00207411.2017.1294969 .

Article   Google Scholar  

Beinecke RH. Addressing the mental health needs of victims and responders to the Boston Marathon bombings. Int J Ment Health. 2014;43(2):17–34. https://doi.org/10.2753/IMH0020-7411430202 .

Dobalian A, Callis R, Davey VJ. Evolution of the Veterans Health Administration’s role in emergency management since September 11, 2001. Disaster Med Public Health Prep. 2011;5(S2):S182–4. https://doi.org/10.1001/dmp.2011.61 .

Heslin KC, Stein JA, Dobalian A, Simon B, Lanto AB, Yano EM, et al. Alcohol problems as a risk factor for postdisaster depressed mood among U.S. veterans. Psychol Addict Behav. 2013;27(1):207–13. https://doi.org/10.1037/a0030637 .

Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, et al. Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry. 2007;70(4):283–337. https://doi.org/10.1521/psyc.2007.70.4.283 .

Jacobs J, Oosterbeek M, Tummers LG, Noordegraaf M, Yzermans CJ, Duckers MLA. The organization of post-disaster psychosocial support in the Netherlands: a meta-synthesis. Eur J Psychotraumatol. 2019;10(1):1544024. https://doi.org/10.1080/20008198.2018.1544024 .

North CS, Pfefferbaum B. Mental health response to community disasters: a systematic review. JAMA. 2013;310(5):507–18. https://doi.org/10.1001/jama.2013.107799 .

Watson PJ, Ruzek JI. Academic/state/federal collaborations and the improvement of practices in disaster mental health services and evaluation. Admin Pol Ment Health. 2009;36(3):215–20. https://doi.org/10.1007/s10488-009-0212-4 .

Thordardottir EB, Gudmundsdottir B, Petursdottir G, Valdimarsdottir UA, Hauksdottir A. Psychosocial support after natural disasters in Iceland-implementation and utilization. Int J Disaster Risk Reduction. 2018;27:642–8. https://doi.org/10.1016/j.ijdrr.2017.11.006 .

Fergusson DM, Horwood LJ, Boden JM, Mulder RT. Impact of a major disaster on the mental health of a well-studied cohort. JAMA Psychiatry. 2014;71(9):1025–31. https://doi.org/10.1001/jamapsychiatry.2014.652 .

Gray L, MacDonald C, Mackie B, Paton D, Johnston D, Baker MG. Community responses to communication campaigns for influenza A (H1N1): a focus group study. BMC Public Health. 2012;12(1):1–12.

Compton MT, Cibulas BK, Gard B, Kaslow NJ, Kotwicki RJ, Reissman DB, et al. Incorporating community mental health into local bioterrorism response planning: experiences from the DeKalb County Board of Health. Community Ment Health J. 2005;41(6):647–63. https://doi.org/10.1007/s10597-005-8846-5 .

Pfefferbaum B, Flynn BW, Schonfeld D, Brown LM, Jacobs GA, Dodgen D, et al. The integration of mental and behavioral health into disaster preparedness, response, and recovery. Disaster Med Public Health Prep. 2012;6(1):60–6. https://doi.org/10.1001/dmp.2012.1 .

Elrod CL, Hamblen JL, Norris FH. Challenges in implementing disaster mental health programs: state program directors’ perspectives. Ann Am Acad Pol Soc Sci. 2016;604(1):152–70.

Gil-Rivas V, Kilmer RP. Building community capacity and fostering disaster resilience. J Clin Psychol. 2016;72(12):1318–32. https://doi.org/10.1002/jclp.22281 .

Melmer P, Carlin M, Castater CA, Koganti D, Hurst SD, Tracy BM, et al. Mass casualty shootings and emergency preparedness: a multidisciplinary approach for an unpredictable event. J Multidiscip Healthc. 2019;12:1013–21. https://doi.org/10.2147/JMDH.S219021 .

Naturale A, Lowney LT, Brito CS. Lessons learned from the Boston Marathon bombing victim services program. Clin Soc Work J. 2017;45(2):111–23. https://doi.org/10.1007/s10615-017-0624-7 .

Reifels L, Pietrantoni L, Prati G, Kim Y, Kilpatrick DG, Dyb G, et al. Lessons learned about psychosocial responses to disaster and mass trauma: an international perspective. Eur J Psychotraumatol. 2013;4.

Dobalian A. The US Department of veterans affairs and sustainable health care coalitions. Disaster Med Public Health Prep. 2015;9(6):726–7. https://doi.org/10.1017/dmp.2015.136 .

Schmitz S, Wyte-Lake T, Dobalian A. Facilitators and barriers to preparedness partnerships: a veterans affairs medical center perspective. Disaster Med Public Health Prep. 2018;12(4):431–6. https://doi.org/10.1017/dmp.2017.92 .

VA Fourth Mission Summary [ https://www.va.gov/health/coronavirus/statesupport.asp ].

Office of Public and Intergovernmental Affairs [ https://www.va.gov/opa/pressrel/searchResults.cfm ].

Affairs USDoV: VA Office of mental health and suicide prevention guidebook. 2018.

Google Scholar  

Lawrence Q. VA secretary Wilkie: ‘We are the surge force’. In: The coronavirus crisis: NPR. NPR.org ; 2020.

Services UDoHH. HHS, FEMA, DOD and VA continue to provide sustained and critical medical care support for Puerto Rico as part of Trump Administration response to Hurricane Maria. In . HHS.gov News: US Department of Health & Human Services; 2017.

Steinhauer J. The V.A. Prepares to back up a health care system threatened by coronavirus: The New York Times; 2020.

Agency FEM. Super typhoon Yutu: one year later: FEMA; 2019.

Foundation NP: After-action review of the orlando fire department response to the attack at pulse nightclub. 2018.

Investigation FBo: Active shooter incidents in the United States in 2016 an 2017. 2018.

Department LVMP: 1 October after action review. 2018.

Charmaz K, Belgrave LL. Grounded theory: The Blackwell Encyclopedia of Sociology; 2007. https://doi.org/10.1002/9781405165518.wbeosg070 .

Lowe SR, Galea S. The mental health consequences of mass shootings. Trauma Violence Abuse. 2017;18(1):62–82. https://doi.org/10.1177/1524838015591572 .

Department of Veterans Affairs. National incident management system compliance: VHA Directive 0320.12(1): Administration VH. Washington, DC; 2021.

Veterans Health Administration. COVID-19 response plan: Management OoE; 2020.

US Department of Defense DoVA, Department of Health & Human Services. Interagency task force on military and veterans mental health; 2017. p. 1–31.

National Academies of Sciences E, and Medicine, Health and Medicine Division, Board on Health Care Services, Committee to Evaluate the Department of Veterans Affairs Mental Health Services. Evaluation of the Department of Veterans Affairs Mental Health Services: National Academies Press (US); 2018.

Subica AM, Aitaoto N, Link BG, Yamada AM, Henwood BF, Sullivan G. Mental health status, need, and unmet need for mental health services among U.S. Pacific islanders. Psychiatr Serv. 2019;70(7):578–85. https://doi.org/10.1176/appi.ps.201800455 .

Buettner K, Sablan J, Funk M, Arriola, J, Price, S, Sugiura, K, Diminic S, Drew N. WHO profile on mental health in development (WHO proMIND): Commonwealth of the Northern Mariana Islands. Geneva, World Health Organization; 2013. https://apps.who.int/iris/bitstream/handle/10665/85304/9789241505741_eng.pdf;jsessionid=A222F532F705877A650948706A437484 . Accessed 26 Mar 2021.

Mental health in the Asian Americans/Pacific Islander Community [ https://www.amsa.org/2020/09/04/mental-health-in-the-asian-americans-pacific-islander-community/#:~:text=Mental%20Health%20of%20Pacific%20Islanders&text=According%20to%20a%202019%20study%20for%20the%20general%20US%20population ].

Alessi EJ. Acknowledging the impact of social forces on sexual minority clients: introduction to the special issue on clinical practice with LGBTQ populations: Springer; 2013.

Veteran Population [ https://www.va.gov/vetdata/veteran_population.asp ].

Ussher JM. Heterocentric practices in health research and health care: implications for mental health and subjectivity of LGBTQ individuals. Fem Psychol. 2009;19(4):561–7. https://doi.org/10.1177/0959353509342933 .

LGBTQI [ https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI ].

Stults CB, Kupprat SA, Krause KD, Kapadia F, Halkitis PN. Perceptions of safety among LGBTQ people following the 2016 pulse nightclub shooting. Psychol Sex Orientat Gend Divers. 2017;4(3):251–6. https://doi.org/10.1037/sgd0000240 .

Lesbian, Gay, Bisexual and Transgender Veteran Care [ https://www.orlando.va.gov/services/lgbt/index.asp ].

National Academies of Sciences E, and Medicine. Evaluation of the Department of Veterans Affairs Mental Health Services: National Academies of Sciences E, and Medicine; 2018.

Download references

Acknowledgements

Not applicable.

This work was supported by the US Department of Veterans Affairs, Veterans Health Administration, Office of Emergency Management and the Office of Population Health. The views expressed in this presentation are those of the author and do not necessarily reflect the position or policy of the VA or the US government.

Author information

Authors and affiliations.

Department of Veterans Affairs, Veterans Emergency Management Evaluation Center (VEMEC), 16111 Plummer St. MS-152, North Hills, CA, 91343, USA

Tamar Wyte-Lake, Susan Schmitz & Aram Dobalian

Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA

Tamar Wyte-Lake

Orlando VA Medical Center, 13800 Veterans Way, Orlando, FL, 32728, USA

Reginald J. Kornegay

VA Southern Nevada Healthcare System, 6900 N. Pecos Road, North Las Vegas, NV, 89086, USA

Felix Acevedo

Division of Health Systems Management and Policy, University of Memphis School of Public Health, Memphis, TN, USA

Aram Dobalian

You can also search for this author in PubMed   Google Scholar

Contributions

TWL and SS planned the study, including instrumentation, conducted the data analysis, and wrote the paper. RJK and FA supported the qualitative analysis and contributed to revising the paper. AD helped to plan the study and contributed to revising the manuscript. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Tamar Wyte-Lake .

Ethics declarations

Ethics approval and consent to participate.

The Greater Los Angeles VA Healthcare System Institutional Review Board (Los Angeles, CA USA) approved this study. As the research presented no more than minimal risk of harm to subjects and involved no procedures for which written consent would be normally required outside of the research context, the study received a waiver for documentation of consent from the Institutional Review Board, and verbal, recorded audio consent was approved.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1..

2017 Disaster Qualitative Study: Collaboration Project Interview Guide. Interview guide utilized during project’s semi-structured interviews.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Wyte-Lake, T., Schmitz, S., Kornegay, R.J. et al. Three case studies of community behavioral health support from the US Department of Veterans Affairs after disasters. BMC Public Health 21 , 639 (2021). https://doi.org/10.1186/s12889-021-10650-x

Download citation

Received : 05 August 2020

Accepted : 18 March 2021

Published : 01 April 2021

DOI : https://doi.org/10.1186/s12889-021-10650-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Emergency preparedness
• Behavioral health; disaster response
• US Department of Veterans Affairs

BMC Public Health

ISSN: 1471-2458

• General enquiries: [email protected]

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

Part 2 Lucy’s Story

2.4 Lucy case study 3: Mental illness diagnosis

Nicole Graham

Introduction to case study

Lucy has experienced the symptoms of mental illness during her lifespan; however, it was not until her early twenties that she was formally diagnosed with bipolar affective disorder. In the case study below, we explore the symptomology that Lucy experienced in the lead up to and post diagnosis. Lucy needs to consider her mental illness in relation to her work as a Registered Nurse and as she continues to move through the various stages of adulthood.

Learning Objectives

By the end of this case study, you should be able to:

• Identify and consider the symptoms of mental illness.
• Develop an understanding of contributing biopsychosocial stressors that may exacerbate the symptoms of mental illness as experienced by Lucy.
• Critically analyse the professional, ethical, and legal requirements and considerations for a registered health professional living with chronic illness.

Lucy’s small group of friends describe her as energetic and ‘a party person’. Although she sometimes disappears from her social group for periods of time, her friends are not aware that Lucy experiences periods of intense depression. At times Lucy cannot find the energy to get out of bed or even get dressed, sometimes for extended periods. As she gets older, these feelings and moods, as she describes them, get more intense. She loves feeling high on life. This is when she has an abundance of energy, is not worried about what people think of her and often does not need to sleep. These are the times when she feels she can achieve her goals. One of these times is when she decides to become a nurse. She excels at university, loves the intensity of study, practice and the party lifestyle. Emergency Nursing is her calling. The fast pace, the quick turnaround matches her endless energy. The fact that she struggles to stay focused for extended periods of time is something she needs to consider in her nursing career, to ensure it does not impact negatively on her care.

Unfortunately, Lucy has experienced challenges in her career. For example, her manager often comments on her mental illness after she had openly disclosed her diagnosis. It is challenging for her to hear her colleagues speak badly about a person who presents with mental illness. The stigma she hears directed at others challenges her. She is also very aware that it could be her presenting to the Emergency Department when she is unwell and in need of further support. Lucy is constantly worried that her colleagues will read her medical chart and think she is unsafe to practice.

While the symptoms that cause significant distress and disruption to her life began in her late teens, they intensified after she commenced antidepressant medication after the loss of her child. She subsequently ceased taking them due to side effects. These medications particularly impact on her ability to be creative and reduce her libido and energy. By the time she turns 18, she notices more frequent, intense mood swings, often accompanied by intense feelings of anxiety. During her high periods, Lucy enjoys the energy, the feeling of euphoria, the increased desire to exercise, her engagement with people, and being impulsive and creative. Lucas appreciates her increased libido. However, during these periods of high mood, Lucy also has impaired boundaries and is often flirtatious in her behaviour towards both friends and people she doesn’t know. She also increases her spending and has limited sleep. Lucas is often frustrated by this behaviour, leading to fights. On occasion Lucas slaps her and gets into fights with the people she is flirting with. These periods can last days and sometimes weeks, always followed by depressive episodes.

When she is in the low phases of her mood, Lucy experiences an overwhelming sense of hopelessness and emptiness. She is unable to find the energy to get out of bed, shower or take interest in simple daily activities. Lucas gets frustrated and dismisses Lucy’s statements of wanting to end her life as ‘attention seeking’. Lucy often expresses the desire to leave this world when she feels this way. When Lucas seeks support from the local general practitioner, nothing really gets resolved. The GP prescribes the medication; Lucy regains her desire to participate in life; then stops the medication due to side effects which extend to gastrointestinal upsets, on top of the decrease in libido and not feeling like herself. When Lucy is referred to a psychologist, she does not engage for more than one session, saying that she doesn’t like the person and feels they judge her lifestyle. When the psychologist attempts to explore a family history of mental illness, Lucy says no- one in her family has it and dismisses the concept.

The intense ups and downs are briefly interrupted with periods of lower intensity. During these times, Lucy feels worried about various aspects of her life and finds it challenging to let go of her anxious thoughts. There are times when Lucy has symptoms like racing heart, gastrointestinal update and shortness of breath. She spends a great deal of time wanting her life to be better. Her desire to move on from Lucas and to start a new life becomes more intense. Lucy is confident this is not a symptom of depression; it is just that she is unhappy in her relationship. Lucy starts to consider career options, feeling that not working affects her lifestyle, freedom and health. As she explores different options on the internet, Lucy comes across a chat room. Using the chat name ‘Foxy Lady 20’, she develops new friendships. She finds herself talking a lot with a man named Lincoln who lives on the Gold Coast.

After a brief but intense period talking with Lincoln online, Lucy abruptly decides to leave Lucas and her life in Bundaberg to move in with Lincoln. Lincoln, aged 26, 5 years older than Lucy, owns a modest home on the Gold Coast and has stable employment at the local casino. Their relationship progresses quickly and within a month Lincoln has proposed to Lucy. They plan to marry within 12 months.

Lucy is now happy with her life and feels stable. She decides to pursue a degree in nursing at the local university. Lucy enrols and makes many new friends, enjoying the intensity of study and a new social scene. Her fiancé Lincoln also enjoys the social aspects of their relationship. During university examination periods, Lucy experiences strong emotions. At the suggestion of an academic she respects, she makes an appointment with the university counselling service. After the first 3 appointments, Lucy self-discovers, with the support of her counsellor, that she might benefit from a specialist consultation with a psychiatrist. She comes to recognise that her symptoms are not within the normal range experienced by her peers. Lincoln is incredibly supportive and attends the appointments with Lucy, extending on the information she provides. Lucy reveals information about her grandmother, who was considered eccentric, and known for her periods of elevated mood and manic behaviour. The treating psychiatrist suggests Lucy may be living with bipolar affective disorder and encourages her to trial the medication lithium.

Lucy does not enjoy the side effects of decreased energy, nausea and feeling dazed and ceases taking the lithium during the university break period. This causes Lucy to again experience an intense elevation of her mood, accompanied by risk-taking behaviours. Lucy goes out frequently, nightclubbing and being flirtatious with her friends. She becomes aggressive towards a woman who confronts Lucy about her behaviour with her boyfriend in the nightclub. This is the first time Lucy exhibits this type of response, along with very pressured speech, pacing and an inability to calm herself. The police are called. They recommend Lucy gets assessed at the hospital after hearing from Lincoln that she has ceased her medication. Lucy is admitted for a brief period in the acute mental health ward. After stabilising and recommencing lithium, Lucy returns to the care of her psychiatrist in the community. The discharge notes report that Lucy had been previously diagnosed with bipolar disorder, may also be experiencing anxiety related symptoms, and have personality vulnerabilities.

Lucy is in the final year of her university studies when she has a professional experience placement in the emergency ward. Lucy really enjoys the fast pace, as well as the variety of complex presentations. Lucy feels it matches her energy and her desire for frequent change. After she completes her studies, Lucy applies and is successful in obtaining a position at the local hospital. Throughout her initial graduate year, Lucy balances life with a diagnosis of mental illness as well as a program of her own self-care. She finds the roster patterns in particular incredibly challenging and again becomes unwell. She goes through a period of depression and is unable to work. During this period, Lucy experiences an overwhelming sense of hopelessness and considers ending her life. Again, she requires a higher level of engagement from her treating team. Lucy agrees she is not fit to work during this time and has a period of leave without pay to recover. She has disclosed to her manager that she has been diagnosed with a mental illness and later discusses how shift work impacts her sleep and her overall mental wellbeing.

Over time, Lucy develops strategies to maintain wellness. However, she describes her relationship with the Nursing Unit Manager as strained, due to her inability to work night shift as her medical certificate shows. Lucy says she is often reminded of the impact that her set roster has on her colleagues. Lucy also feels unheard and dismissed when she raises workplace concerns, as her manager attributes her feelings to her mental health deteriorating. Lucy has a further period when her mental health deteriorates. However, this time it is due to a change in her medication.

As Lucy and Lincoln have a desire to have a child, Lucy was advised that she cease lithium in favour of lamotrigine, to reduce the risk of harm to the baby. Lucy ceases work during the period when her mental health deteriorates during the initial phase of changing medication. Lucy recommences lithium after she ceases breastfeeding their son at 4 months, with good effect and returns to work.

Case study questions

• Consider the symptoms that Lucy experiences and indicate whether they align with the suggested diagnosis.
• Identify the biopsychosocial contributing factors that could impact mental health and wellness.
• Review and identify the professional disclosure requirements of a Registered Nurse who lives with mental illness in your local area.
• Identify self-care strategies that Lucy or yourself as a health professional could implement to support mental health and wellbeing.

 Thinking point

Sometimes people do not agree with a diagnosis of mental illness, which can be incorrectly labelled as ‘denial’ by health professionals. It is possible that the person is unable to perceive or be aware of their illness. This inability of insight is termed anosognosia (Amador, 2023). The cause of anosognosia in simple terms can be due to a non-functioning or impaired part of the frontal lobe of the brain, which may be caused by schizophrenia, bipolar disorder or other diseases such as dementia (Kirsch et al., 2021).

As healthcare workers will likely care for someone who is experiencing anosognosia, it is important to reflect on how you may work with someone who does not have the level of insight you would have hoped. Below is a roleplay activity whereby you can experience what it might be like to communicate with someone experiencing anosognosia. Reflect on your communication skills and identify strategies you could use to improve your therapeutic engagement.

Role play activity – Caring for a person who is experiencing anosognosia

Learning objectives.

• Demonstrate therapeutic engagement with someone who is experiencing mental illness
• Identify effective communication skills
• Reflect on challenges and identify professional learning needs

Resources required

• Suitable location to act out scene.
• One additional person to play the role of service user.

Two people assume role of either service user or clinician. If time permits, switch roles and repeat.

• Lucy has been commenced on lithium carbonate ER for treatment of her bipolar disorder.
• Lucy is attending the health care facility every week, as per the treating psychiatrist’s requests.
• The clinician’s role is to monitor whether Lucy is experiencing any side effects.

Role 1 – Clinician

• Clinician assumes role of health care worker in a health care setting of choice.
• Lucy has presented and your role is to ask Lucy whether she is experiencing any side effects and whether she has noticed any improvements in her mental state.

Role 2 – Lucy who lives with bipolar

• Lucy responds that she does not understand the need for the tablets. She also denies having a mental illness. Lucy says she will do what she is told, but does not think there is anything wrong with her. Lucy thinks she is just an energetic person who at times gets sad, which she describes as ‘perfectly normal.’ Lucy is not experiencing any negative side effects, but says she would like clarification about why the doctor has prescribed this medication.

Post role play debrief

Reflect and discuss your experiences, both as Lucy and as the clinician. Identify and discuss what was effective and what were the challenges.

Identify professional development opportunities and develop a learning plan to achieve your goals.

Additional resources that might be helpful

• Australian Prescriber: Lithium therapy and its interactions
• LEAP Institute: The impact of anosognosia and noncompliance (video)

Key information and links to other resources

Fisher (2022) suggests there are large numbers of health professionals who live with mental illness and recognise the practice value that comes with lived experience. However, the author also notes that as stigma is rife within the health care environment, disclosing mental illness can trigger an enhanced surveillance of the health professional’s practice or impede professional relationships (Fisher, 2022).

It is evident that the case studies derived from Lucy’s life story are complex and holistic care is essential. The biopsychosocial model was first conceptualised in 1977 by George Engel, who suggests it is not only a person’s medical condition, but also psychological and social factors that influence health and wellbeing (Engel,2012).

Below are examples of what you as a health professional could consider in each domain.

• Biological: Age, gender, physical health conditions, drug effects, genetic vulnerabilities
• Psychological:  Emotions, thoughts, behaviours, coping skills, values
• Social:  Living situation, social environment, work, relationships, finances, education

Developing skills through engaging in reflective practice and professional development is essential. Each person is unique, which requires you as the professional to adapt to their particular circumstances. The resources below can help you develop understanding of both regulatory requirements and the diagnosis Lucy is living with.

Organisations providing information relevant to this case study

• Rethink Mental Illness: Bipolar disorder
• Australian Health Practitioner Regulation Agency (AHPRA): Resources – helping you understand mandatory notifications
• Australian Health Practitioner Regulation Agency (AHPRA): Podcast – Mental health of nurses, midwives and the people they care for
• Black Dog Institute: TEN – The essential network for health professionals
• Borderline Personality Disorder Community
• National Institute of Mental Health (NIMH): Anxiety disorders

 Case study 3 summary

In this case study, Lucy’s symptoms of mental illness emerge in her teenage years. Lucy describes periods of intense mood, both elevated and depressed, as well as potential anxiety-related responses. It is not until she develops a therapeutic relationship with a university school-based counsellor that she realises it might be beneficial to engage the services of a psychiatrist. After she is diagnosed with bipolar affective disorder she engages in treatment. Lucy shares her experience of both inpatient and community treatment as well as her professional practice requirements in the context of her mental illness.

Amador, X. (2023). Denial of anosognosia in schizophrenia. Schizophrenia Research , 252 , 242–243. https://doi.org/10.1016/j.schres.2023.01.009

Engel, G. (2012). The need for a new medical model: A challenge for biomedicine. Psychodynamic Psychiatry, 40 (3), 377–396. https://doi.org/10.1521/pdps.2012.40.3.377

Fisher, J. (2023). Who am I? The identity crisis of mental health professionals living with mental illness. Journal of Psychiatric and Mental Health Nursing . Advance online publication. https://doi.org/10.1111/jpm.12930

Kirsch, L. P., Mathys, C., Papadaki, C., Talelli, P., Friston, K., Moro, V., & Fotopoulou, A. (2021). Updating beliefs beyond the here-and-now: The counter-factual self in anosognosia for hemiplegia. Brain Communications , 3 (2), Article fcab098. https://doi.org/10.1093/braincomms/fcab098

Case Studies for Health, Research and Practice in Australia and New Zealand Copyright © 2023 by Nicole Graham is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

Share This Book

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Pryjmachuk S, Elvey R, Kirk S, et al. Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study. Southampton (UK): NIHR Journals Library; 2014 Jun. (Health Services and Delivery Research, No. 2.18.)

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study.

Chapter 5 the case study.

This chapter focuses on Stage 2, the empirical – or ‘primary research’ – aspect of the study, which we conducted using the case study method. We start with an outline of the specific research methods used, after which we provide a descriptive overview of the individual case study sites; we then present our findings, organised according to a number of analytical themes.

This stage of the project was designed to inform research objectives 3 and 4, which were concerned with, respectively, the factors influencing the acceptability of mental health self-care support services for CYP and the barriers affecting the implementation of such services. In addition, as with the mapping exercise (see Chapter 4 ), this stage of the study also helps realise objective 5, which was concerned with the interface between the NHS and other service providers in the provision of mental health self-care support services for CYP.

Stage 2 was conducted as a collective case study . A case study is an empirical enquiry that focuses on a single phenomenon in its real-life context, especially useful (as in our circumstances) when description or explanation is required. 181 Collective case studies are those in which multiple cases are studied simultaneously or sequentially in an attempt to generate a broad appreciation of a particular issue. 182 Yin 181 (p. 6) defines a ‘case’ as a ‘bounded entity’, a broad and flexible definition that allows the case to be as varied as an event, an individual, a service or a policy. In this project we have defined the case as a ‘mental health self-care support service for CYP in England and Wales’.

Sampling and recruitment

A purposive sampling strategy was employed to ensure that the various dimensions of the self-care support typology we derived from the mapping exercise and systematic reviews (see Chapter 4 , Table 19 ) were reflected in our sample. Accordingly, sites were recruited to include a variety of theoretical bases (e.g. cognitive–behavioural, social learning, recovery) and platforms (e.g. face-to-face or remote, group or individual). We also recruited on the basis of organisational characteristics, such as the sector the site operated in (e.g. NHS vs. local authority vs. voluntary sector) and the site leaders (e.g. health professionals vs. other trained workers vs. volunteers). It was also important to include key characteristics of the study population; thus, the sample included sites offering condition-specific and more generic support, CYP from different age groups, and different types of location (urban, rural) across England and Wales. Using the typology and these characteristics, six potential sites were selected from our sampling frame of 33 services (delivered by 27 providers), and these were approached to participate in the study. One site declined to participate so an alternative, similar in terms of typology dimensions and characteristics to the site that declined, was invited to participate and agreed.

The six sites which agreed to participate were:

• a psychotherapy group for young people aged 14–17 years who self-harm and their families, provided by the NHS in an urban area of England
• a group intervention (Dina School) for children aged 5–6 years with emotional and behavioural difficulties (EBD), based on The Incredible Years 183 programme and provided in rural Wales by the voluntary sector
• a parenting group for parents of children with EBD, based on The Incredible Years 183 programme and operating in rural Wales as a joint NHS/local authority initiative
• a resilience-focused family support service for families of children aged 5–14 years with emerging EBD, provided by the voluntary sector (but local authority funded) and operating in an urban area of England
• a national, recovery-focused online support group for young people aged up to 25 years with eating disorders
• a supported online cognitive–behavioural intervention (Beating the Blues 184 ) provided to young people aged 14–30 years with depression and/or anxiety by the voluntary sector in an urban area of England.

Recruitment of participants at the case study sites was also purposive in that it was driven by the characteristics of the particular self-care model employed. Additionally, to ensure a range of relevant perspectives, the views of younger, as well as older, children, and those of parents and staff with differing roles providing the services were sought.

Regarding the recruitment of service user participants (i.e. CYP and their parents), we received valuable advice from the SAG on engaging these participants in the study. Recruitment documentation (the covering letter, participant information sheets, contact form and consent/assent forms; see Research ethics and governance below) was developed with guidance and feedback from CYP. At five of the sites, staff provided the recruitment documentation to current and ex-service users (or to their parents if they were aged 14 years or below), via the post or by handing the documentation to users when they attended the self-care support service. Participants provided their contact details using the contact form and the researcher (Elvey) telephoned them to arrange the interview. For the eating disorders online support site, the study was publicised, including contact details for the research team, on a web page listing details of current research projects wanting to recruit participants, via an e-mail distribution list of service users who were willing to be contacted about research projects, and via the site’s Twitter feed. CYP participants were eligible to participate only if they were aged between 5 and 17 years. Although two of the sites (sites 5 and 6) did not offer services specifically tailored for CYP, they were eligible for this study because they did offer services to those under the age of 18 years. Non-professional participants (i.e. CYP and parents) were offered £10 in gift vouchers as a token of thanks for their participation.

Recruitment of staff at each site was facilitated via a key contact, usually a service manager, who not only took part in the research, but also identified additional relevant staff to invite as participants. At five of the six sites, staff were provided with the recruitment documentation, either through the post or in person by the researcher; at the eating disorders site, documentation was supplied via e-mail.

Research ethics and governance

Like all empirical research conducted within a university setting, the case study was subject to ethical approval by the host institution, the University of Manchester. Moreover, because the research involved potential access to NHS sites and NHS patients, the ethical aspects of the study required consideration by the NHS National Research Ethics Service (NRES) prior to any consideration by the university. Regulations introduced by NRES in 2011 185 allowed an expedited proportionate ethical review in circumstances where a project had no material ethical issues . NRES provides a tool 186 to help researchers identify whether there are material ethical issues or not, and use of this tool suggested that our project might be eligible for such an expedited review. This turned out to be the case and a favourable ethical opinion was obtained through proportionate review in March 2012. As is the standard procedure, this favourable opinion was accepted by the University of Manchester Research Ethics Office shortly afterwards. While conducting the case study research, it was necessary, on two occasions (in September 2012 and October 2012), to inform NRES of a ‘substantial amendment’ to the ethics-approved protocol. One amendment was required because one site requested that the wording on the covering letter be modified to remove the term ‘mental health’. The other arose because another site worked predominantly with children aged 5 years, so we asked that our original lower age limit for CYP participants be reduced from 6 to 5 years. Both of these amendments NRES subsequently approved.

Ethical research is underpinned by three inter-related factors: (1) informed consent; (2) the safety of participants and researchers; and (3) the safeguarding of any data obtained during the course of the research.

Regarding informed consent, all identifiable participants received an age-appropriate participant information sheet informing them of the study’s nature and purpose. The participant information sheets and associated consent/assent forms were designed according to NRES guidance. 187 The versions specific to CYP, furthermore, were piloted with colleagues’ children, students at a local secondary school and young people with experience of mental health services, and were subsequently amended as a result of their feedback. Written consent was obtained from all adult participants. In line with NRES guidance, 187 all CYP participants aged 15–17 years provided their own written consent; parents provided written consent for children under 15 years old, although, in line with good practice, written assent was also obtained from these children. We needed to take a slightly different approach to consent for the online eating disorders support group (site 5). We were interested in postings on the site’s discussion boards – postings that were both anonymous and publicly available. As the postings were anonymous, it would have been very difficult to obtain individual consent for the use of these postings, so we obtained ‘proxy’ consent to access and use these postings from the eating disorders organisation providing the service.

Regarding the safety of participants and researchers, the principal risks identified for participants were that they might get upset during the interview or disclose information (e.g. in relation to child protection) that would require action by the researcher. Written protocols were prepared for both of these situations. Risks to researcher safety were minimised by adherence to the University of Manchester’s guidance on lone working.

Data safeguarding requires that confidentiality and anonymity issues be addressed, not only in the conduct of the research but also in the reporting and storage of any data associated with the research. To preserve anonymity, the data generated by the research were, wherever possible, stored with identifying features removed. In any case, the data were stored securely, with due regard to confidentiality and in accordance with the University of Manchester’s information governance regulations. When the data were circulated around the study team or SAG, analysed or (as is the case here) reported, we ensured that any identifying features were removed.

At each case study site, we complied with any specific research governance requirements. This included complying with NHS Research and Development requirements at the NHS sites selected.

Data collection and management

Case study research requires data from a variety of sources and, once collected, the data should be managed systematically. 181 Data were obtained through semistructured interviews, documentary review and virtual non-participant observation and, wherever possible, from all three participant categories: CYP, parents and staff.

Semistructured interviews

Semistructured interviews were used as the main data collection technique. They were conducted with staff at all six sites and with CYP and/or parents at all sites except the eating disorders online support site. Pragmatism largely dictated the way in which participants were interviewed in that they were given choices as to which approach they preferred (e.g. telephone vs. face to face; individual vs. group). Forty-two interviews involving 52 participants were conducted; 37 were conducted in person, either at the site’s premises or at the service user’s home, and five were conducted via the telephone. The majority of interviews (35/42) were individual, five were joint interviews with a child or young person plus parent, one was a group interview with a child, parent and sibling and one was a focus group of four young people. The interviews ranged in length from 10 minutes (for some of the youngest children, aged 5 and 6 years) to 1 hour and 20 minutes. Interviews were facilitated by the use of topic guides, copies of which can be found in Appendix 12 . All of the interviews were digitally audio recorded with the permission of participants and the recordings were subsequently transcribed verbatim by a professional company.

Documentary review

Where available, relevant documentary evidence was collected from each site. For sites 5 and 6, documentary evidence was obtained simply from the relevant websites of the services. More comprehensive data were obtained from the other four sites, including a referrer’s leaflet for site 1 as well as a printed self-injury ‘toolkit’ used in providing the self-care support service there; a Microsoft PowerPoint general presentation about the Incredible Years services at sites 2 and 3, and one about the funder’s strategic plan regarding these services; an information leaflet about Dina School training for teachers at site 2; and information leaflets about the site 4 service for referrers, parents and CYP. The documentary evidence largely served to provide a contextual background to, and additional understanding of, the six sites.

Virtual non-participant observation

For the eating disorders online support site (site 5), we collected the data via ‘netnographic’ non-participation observation, adopting the principles of a method designed specifically for health-care research. 188 , 189 Netnography is a form of ethnography used in the study of online behaviour, and as ethnography concerns everyday routine behaviours in a natural setting, 190 netnography was an entirely appropriate method of observing a service that operated entirely online. The service centred around discussion threads that were organised by the providers into nine boards, following themes such as ‘recovery’, ‘caring about someone’, ‘introductions’ and ‘poetry’. Two boards were excluded from the study as the content merely described how to use the boards. All postings over a 4-month period (August to November 2012) were collected from the remaining seven boards. These comprised 114 discussion threads with more than 500 individual messages, each of which was screened for relevance. The postings were copied from the website and pasted into Microsoft Word 2010 documents (Microsoft Corporation, Redmond, WA, USA) prior to analysis.

Regarding management and coding of the data, the three data sets – interview transcripts, background information about the sites (documentary evidence) and the online group postings – were imported into NVivo 10 (QSR International, Warrington, UK), computer software designed to assist in the collection, organisation and analysis of qualitative and mixed-methods data.

Data analysis

The data were analysed using the framework method, 191 , 192 which has five stages: (1) familiarisation; (2) identifying a thematic framework; (3) indexing; (4) charting; and (5) mapping and interpretation. For the interview data, familiarisation was achieved by all of the transcripts being read by the team member who conducted the interviews (Elvey; Kendal also facilitated one group interview), and through other members of the research team (Kirk; Kendal; Pryjmachuk; Catchpole) each reading a sample of transcripts. For the virtual non-participation observation data (site 5’s online postings), Elvey and Kendal undertook an analogous process in that they treated the Word documents into which the postings had been pasted as ‘transcripts’. Following familiarisation, the study’s research questions and the topic guides (see Appendix 12 ) were used to devise an initial thematic framework. Using this initial framework, data from the transcripts (including the online postings) and the background documents obtained from each site were then indexed by Elvey in order to produce an initial chart for each of the six sites. An example of such a chart is provided in Appendix 13 . These six charts were then circulated around team members and a final thematic framework was developed through an iterative process, whereby we met as a team several times to discuss the data and any emerging salient themes. As the final thematic framework emerged, the data from the six initial charts were assimilated into a single chart which was used to guide our analysis and interpretation of the case study findings. The final thematic framework is outlined in Table 22 in the Findings section of this chapter, and Appendix 14 illustrates (using one of the themes, ‘facilitating self-care support’, as an example) how data from each of the initial charts were subsequently assimilated into a single chart.

Themes and subthemes emerging from the case study data

• Characteristics of the case study sites

Details of the six case study sites are summarised in Table 20 and described in detail below.

Details of the six case study sites

Site 1: self-harm psychotherapy group

This NHS service was designed for young people aged 14–17 years who self-harm; it also offered some support for the families of these young people via family support groups, and families could telephone the service and talk to staff between sessions. The service was run from an outpatient setting at an NHS mental health hospital. The service operated within a recovery-focused philosophy and was eclectic in its approach, in that the group intervention employed elements of group psychotherapy, CBT, Linehan’s dialectical behaviour therapy 193 and supportive counselling. Groups ran on a weekly basis (weekday mornings), lasted 2 hours and were led by nurses and support workers. Although the service was manualised – in that there was a specific protocol in place for how the service should be delivered – there was no limit, other than reaching the age of 18 years, to the number of weekly sessions a young person could attend. Young people were referred to the service via community or inpatient services.

Site 2: Dina School

The incredible years.

The group for children with emotional and behavioural problems (site 2) and the parenting group (site 3) were interconnected, but separate, services. Both operated as part of Webster-Stratton’s The Incredible Years programme 183 that had been adopted region-wide (across the local authority area) by the commissioning bodies in the region. The Incredible Years is an evidence-based programme, influenced heavily by social learning theory. It emphasises attachment, relationship building and emotional coaching, with a focus on children learning through play and parents and teachers spending time with children, listening to them and giving them positive feedback. The overall Incredible Years programme comprises universal and targeted (indicated) interventions, both of which were available in the region. At the time of data collection, around half of the region’s schools were Incredible Years schools. In these schools, all staff members were trained in the approach and were thus able to implement the programme universally (in a regular classroom setting, for example) or in a more targeted way.

Dina School

Site 2 was an example of a targeted intervention operating in one of the Incredible Years schools. Known as Dina School, it involved children taking part in 18 weekly, small group sessions, which took place in a room at the children’s school. The groups were facilitated by two classroom assistants, who delivered the programme as set out in the Dina School manual. The programme makes use of a dinosaur puppet called ‘Dina’ (which was also used universally in the main classroom setting) as well as two additional character puppets, ‘Wally’ and ‘Molly’. These puppets were used in role plays, demonstrations of behaviours and communication techniques and in video vignettes. Each session followed a similar format, with a review of the ‘homework’ tasks that were set at the previous session, followed by activities and games and the setting of a further homework task at the end. Parents came to collect their children at the end of the session which coincided with the end of the school day.

Site 3: parenting group

Like site 2, site 3 was a targeted programme. It was one of more than 20 Incredible Years group parenting programmes that operated in the same region as site 2, offering parent training to parents of children aged from 0 years upwards, grouped according to the children’s age. The parenting group participating in this study was for parents of preschool children, aged 2–4 years, who wanted support with their child’s behaviour or communication (e.g. being withdrawn or having tantrums that the parent found difficult to deal with). Parents could self-refer or be referred to the service. The service was provided by a voluntary sector organisation and operated from its premises, although it was commissioned and funded jointly by the NHS and local authority. Parents attended 15 weekly group sessions which were facilitated by two members of staff with backgrounds in family and youth work, and in accordance with the programme manual.

Site 4: resilience-focused family support

Site 4 was a voluntary sector family support service provided to families of children aged 5–12 years with complex emotional and behavioural needs who did not require Tier 3 CAMHS care. Some children were referred to the service because their needs were not seen to warrant CAMHS input; others had attended CAMHS and were subsequently referred to this service for the more generalised support with coping and resilience that it offered. The service is based on the Daniel-Wassell model of resilience, 194 a model with six domains – secure base, friendships, talents and interests, education, positive values and social competences – that have some affinity with the principles of recovery. Staff members work through these domains with families to identify the family’s needs and then focus on those domains where the most support is needed. The family support was delivered by a member of staff from the voluntary organisation operating the service. The staff, who had a variety of professional backgrounds including youth work, social work, psychology and nursing, met with the child and his or her parent(s) individually (sometimes together) at home and at school. As with The Incredible Years, this service was manualised with a prescribed number of sessions.

Site 5: online eating disorders discussion board

This site, operated by an eating disorders charity, consisted of online message boards for young people concerned about, or experiencing, eating disorders. The message boards were established around 6 years ago to improve access to support. Although the online eating disorders service was a ‘virtual’ service, operating entirely over the internet, the charity operating the service offered some other services for young people including a telephone helpline and a live online chat service which some message board users had also participated in. Like the self-harm service, this service operated within a recovery-focused philosophy. To post messages, users had to register on the internet site (supplying their name and e-mail address). Although the posts were moderated, they were freely available on the internet for anyone to read. The boards were organised into themes, and users posted messages that mostly described their worries about food or eating, or their experiences of living with eating disorders, as well as messages that sought support from others or offered emotional support and practical tips to others. The boards were moderated by volunteers, many of whom had experienced eating disorders themselves and some of whom had trained in relevant fields such as counselling. Although the service was open to young people up to the age of 25 years, it was eligible as a case study site because those under 18 years of age were represented in the postings. Unlike the other five sites (which were manualised to one degree or another), this service was inherently spontaneous and adaptable.

Site 6: supported online cognitive–behavioural therapy intervention

Site 6 was a charity-operated, supported online CBT service for young people with anxiety or depression aged between 14 and 30 years. Although the service was open to people up to the age of 30 years, it was, like site 5, eligible as a case study site because those under 18 years of age used the service. The service had been established by staff at the site who had had prior experience of anxiety and depression themselves. It was set up in response to a perceived gap in suitable service provision for young people and young adults and aimed to appeal to this group by being accessible and flexible. The site operated as a drop-in centre, whereby people could come without an appointment and access information and advice. Service users came to the charity’s base and worked through a specific online CBT course – Beating the Blues 184 – with a volunteer from the charity facilitating the young person through each CBT session. Like most CBT interventions, this service was manualised with a prescribed number of sessions.

• Participant characteristics

Table 21 summarises the interviews conducted at each case study site. In total, 52 participants were interviewed between July 2012 and March 2013. The CYP ( n  = 17) who took part ranged in age from 5 to 17 years. Of these 17 CYP, four were interviewed as a focus group (at the self-harm group psychotherapy site), and six were interviewed along with a parent, five at the family support site and one at the self-harm site. Of the 15 parents who took part, nine were interviewed individually and six along with their child. Two of the individual parent interviews at the parenting site were conducted via the telephone. The service provider staff interviewed ( n  = 19) included nurses, psychologists, classroom assistants, social workers, youth workers, counsellors and lay volunteers. Three members of staff at the family support, group parenting and eating disorder sites were interviewed over the telephone. The majority of staff and family members were female; two male staff members and three fathers were interviewed. Of the six young people interviewed at the self-harm and anxiety/depression sites, half were male and half female; at the sites where younger children were interviewed, most (8/11) were male.

Participants by site and category

Although the overall quantity of data is sufficient for a case study, 195 a few observations need to be made about the relative success of our recruitment strategy across the six sites. Recruitment was relatively successful for all three participant categories across sites 1, 2 and 4, though only having one parental interview at site 1 was disappointing. Site 3’s recruitment was also reasonably successful given that parents were the target of the service and that, as they were under 5 years of age, we did not have ethical permission to interview the children. We did not attempt to recruit parents at sites 5 and 6 because the very nature of the services at these sites meant that it would be difficult to identify parents. The low numbers of staff participants at these two sites was also understandable because these services – both provided by the voluntary sector – had limited resources to employ significant numbers of staff. With site 5, we did not manage to recruit any CYP participants for interview despite advertising on the service provider’s website and through other online networks. Though disappointing, this is not an especially serious recruitment limitation as any interview data obtained would have merely augmented the CYP’s perspectives on self-care support which we obtained via the netnographic non-participation observation data.

Site 6 perhaps created the most significant recruitment issue in that we only managed to recruit one CYP participant at this site. This site was a relatively newly established service which was operated by a small organisation with one full-time member of staff. We recruited via the service manager who asked that we involve only ex-, not current, users of the service. The service manager searched the contact database and telephoned or sent information to all ex-users inviting them to participate in an interview. During the 7 months that we were in contact with the site, only eight people aged 17 years and below accessed the service. Two agreed to be contacted by the research team and subsequently participated in interviews, one of whom has since taken on a role as a volunteer providing the service.

From the analysis of the case study data, four principal themes emerged, each containing a number of subthemes. These themes and subthemes are summarised in Table 22 and discussed in more detail in the ensuing sections. At this point, however, it can be noted that the first two themes mostly provide contextual detail about, respectively, the users and providers of mental health self-care support services for CYP, whereas the remaining two focus largely on the factors contributing to the acceptability of such services.

Having a mental health problem

This theme provides some contextual detail about CYP’s and their families’ understanding of the mental health problems experienced prior to using the services at the case study sites, their understanding of self-care in the context of these problems and their experiences of any self-care support received.

Understanding the mental health problem

The conceptualisation of CYP’s difficulties specifically as mental health problems appeared to be connected to the CYP’s age. The youngest children interviewed, aged 5 and 6 years, did not describe having any mental health problems or difficulties themselves. School staff and parents tended to think that these children mainly lacked confidence or had difficulties expressing or managing their emotions. Some parents described emotional outbursts and tantrums and two described their children as being ‘unhappy’.

I had concerns about his behaviour; he would break down into quite severe tantrums that would last for 20 minutes . . . he would spit all over the seats . . . strip naked and hit and lash and kick; hurt himself, hurt me. And generally I just felt that I had this unhappy child on my hands … I couldn’t go out with him . . . So I was kind of feeling trapped in my own home because of his behaviour. Parent of younger child

Older, primary school-age children and their parents described various emotional and behavioural problems: being unsettled or disruptive at school; having emotional outbursts at home; having problems with family members or in making friends; lacking confidence; and having communication problems, especially in expressing emotions.

Me and my mum didn’t really use to get along, and not able to cope, like, and with my brother and sister, I didn’t know how to be responsible and stuff. Child

Young people – that is, older children – who had used the self-harm (site 1), eating disorders online support (site 5) and depression/anxiety (site 6) services had a wide range of experiences, from severe mental health problems and diagnosed conditions, to milder symptoms and difficulties. Some attendees at the self-harm site had been diagnosed with depression and others described feelings of low mood, anxiety and intense feelings. Staff at the self-harm group mentioned a variety of self-harm that users presented with, including cutting and burning. Some CYP attending the self-harm (site 1) and family support (site 4) services had experienced more than one type of difficulty or problem, including being bullied at school, not attending school, displaying signs/symptoms of autism, family relationship problems and misuse of alcohol and/or drugs.

Self-care and self-care support

Just as participants described a wide range of mental health problems and difficulties, their experiences of self-care and support for their problems and difficulties prior to accessing the services were also mixed. Obtaining support was sometimes related to their understanding of the specific mental health problem, as in the case of one young person who had struggled with depression over an extended period:

Interviewer: So had you had any help with your depression before you went to the centre?

Young person: No, none, not at all. I had little understanding as well, it wasn’t something that had been spoken about.

Participants generally described undertaking little self-care before coming into contact with the services. Nonetheless, some parents whose children had attended the Dina School groups (site 2) had also previously attended an Incredible Years parenting course and had used some of the approaches at home. A few parents mentioned using techniques from books or television programmes such as Supernanny . Across most of the sites, the situation for many participants was that they came into contact with the services at a point when their problems had emerged, but they had rarely engaged in self-care themselves or received support they were happy with.

With some of the older children (young people), there was some evidence that they could make rational choices regarding self-management, especially when it came to medication:

Young person: I usually forget to take it, or I intentionally go out my way not to take it, because I feel as if I don’t need it and it makes me feel different . . . I was on Sertraline, but it kept me awake and then I was on Mirtazapine and then some other things . . . I didn’t like them . . . I don’t feel as if meds help me.

Another young person: I’m on medication at the moment, because my depression has peaked at the moment . . . so it [the medication] does work.

However, these choices were not always adaptive, as in these examples of young people ‘self-medicating’ with alcohol:

Young person, interviewed in a group: I used to drink and hide in a tree to drink, because my mum wouldn’t allow it, so I used to hide and had to go in a hole and fall out of a tree regularly drinking, that’s how I coped.

Second young person in the group: Yeah. I used to think alcohol helped me, but it used to just make me worse.

Regarding the support received, there were participants at all of the case study sites with experience of accessing some form of health care or support prior to attending the self-care support service; CAMHS, social services, GPs, psychiatrists, paediatricians, school counselling services and social services were all mentioned. For example, some families had a history of contact with social services due to family situations and some parents had sought help because they were concerned that their child might have an autistic spectrum disorder. There were some reports of positive experiences, such as helpful school counsellors, health visitors and other workers:

My outreach worker who works with me to integrate into the community, because I’m, kind of, agoraphobic, I don’t like people, crowds, so he works with me to try and get me into the community. Young person

However, many negative experiences were recounted where families had felt dismissed when they raised concerns, for example, about their children’s behaviour or social understanding and had found support hard to access. The mother of one child who had previously been referred to community-based mental health services had found the care provided inadequate:

It didn’t help much, she used to just enjoy going there because I was doing all the talking, they would watch her play, so it wasn’t . . . [helping her with] expressing her feelings . . . and then it just kind of stopped, they were thinking she didn’t need it, but she’d got so much anger at the time, she wanted to leave the house . . . I was worried for her. Parent

Two settings in particular were singled out for criticism by young people: mainstream schools and inpatient hospital care. Young people had experienced bullying at school, including being bullied about their mental health problems by other students. Some had stopped attending mainstream school and were at school units and felt that staff at mainstream schools often struggled to help students who self-harmed:

They’re not trained in mental health and are only really equipped to do with stuff, like, things to do with education and . . . bullying and peer pressure . . . they’re not equipped . . . they really don’t have a clue when it comes to stuff like mental health and things like self-harm . . . I had a really bad experience with my mentor. Young person

In terms of hospitals, participants described how support for self-harm in inpatient settings focused mainly on preventing physical harm. For example, two participants reported being restrained and put into seclusion (actions which could both be seen as punitive) when staff found that they were in possession of objects which the staff thought the young people would use to self-harm. Participants had found that they could access either group ‘talking therapies’ or an individual to talk to in the units, but had found this problematic because the therapy was not suitable for them at that stage, or because staff did not spend enough time with them:

Young person, interviewed in a group: There’s people there all the time that you can talk to, [but] I think the therapy puts quite a lot more stress on you at the very beginning . . . you’re taken out of your house . . . kind of throw you in with a bunch of new people, that’s hard to deal with . . . it’s a lot harder to then feel comfortable . . . I think, I had therapy twice, it didn’t work, so they basically just left me.

Second young person in the group: [My named nurse] was on nights and then when she was on days, she didn’t speak to me anyway, that was so unhelpful. She came to my room at like half past 10 and I’d be talking about stuff and getting upset and minutes later I had to try and sleep.

Young person: Yeah I had some nights when mine was . . . on nights and the head of [name of department], so he really didn’t have time [for me].

Running throughout the narratives of the young people was a recurring sense of anxiety around accessing support. Feeling alone, not knowing where to turn for help, discomfort and worry about discussing their problems with family or friends were mentioned repeatedly. The following data extract was taken from one of the site 5 message boards:

When you realise youve got some kind of (eating disorder) what was the first thing you all did? It’s just im stuck and going nowhere, the idea of food and excercise is going round and round in my mind, having crazy thoughts in my head all the time- but i cant tell anyone or even talk about it to anyone because i could shy when it comes to spilling out information about myself . . . any help? Pleasepleaseplease . . . ALSO, if you call the youthline what do they ask you and stuff? because I really wanna call them but im scared of the reponse and over the phone (procedure). Young person, verbatim message board posting

Providing self-care support

This section explores the findings relating to staff views about providing self-care support services, their reasons for involvement, training and supervision, and the extent to which their service is integrated with other services.

Service development

Staff at the sites became involved in the services for a variety of reasons: a desire to change things or innovate on the basis of personal, often negative, experiences of mental health services; wanting to improve the evidence base for practice; and often just sheer enthusiasm to help CYP. For example, the manager of one site had been motivated to found an independent alternative to traditional ‘clinical’ approaches on the basis of personal negative experiences elsewhere:

I started to experience the onset of depression and anxiety and looked at what sort of support or help was available to me and there was nothing that I felt I would have been likely to access or appealed . . . so I . . . basically came up with a service that I would have liked to see when I was in that situation and applied for funding and got it. Service lead

At another site, the service lead had been influenced by observations from her own practice, at a time when there was a perceived ‘epidemic’ of self-harm among young people and generally insufficient support available, and when anxiety about the risk of serious harm, including suicide, was high among staff who worked with young people. The rationale behind setting up a group therapy service was that a group approach could be appropriate for young people because of the influence and importance of peer groups to this age group. Moreover, improvements in peers would be clearly visible in a group setting and so serve as a vehicle for hope and optimism in other group members.

The Incredible Years programme, on the other hand, had been adopted at two sites because of its perceived strong evidence base:

I felt really strongly that I knew that the programmes were blueprint [evidence-based] programmes . . . that met the high standards for replicability and for research . . . I really, really like the Incredible Years model. Staff member

Moreover, service development seemed to be coupled with service leads who were enthusiastic and highly motivated, even to the point of being ‘on a mission’:

So it kind of became my mission and it’s grown into the mission for the Authority to develop all of those programmes. Service lead

Across all six case study sites, the attributes of the service leads in particular were suggestive of a high level of leadership skills, in that there was evidence of innovation, planning, empathy (for CYP, parents and colleagues), motivation and communication.

Training and supervision

All of the sites except the online eating disorders site (site 5) were manualised, that is there was a specific written manual in place for how the service should be delivered. The Incredible Years sites (sites 2 and 3) and the anxiety/depression site (site 6) were guided by manuals that prescribed the topics to be covered in each session; the self-harm (site 1) and family support (site 4) services had manuals that were less prescriptive.

At the self-harm site (site 1), all staff running the groups were provided with the service manual and, as part of their training, they also observed groups prior to becoming a group leader. Staff running the groups met monthly for group supervision with the service lead. On its initial formation, staff at the family support service (site 4) had been trained in the resilience approach by its architects. New staff members were first introduced to the model and subsequently trained by the service’s current staff, as well as receiving clinical supervision from a psychologist. At the anxiety/depression site (site 6), training was provided by the company supplying the CBT programme and all volunteers had to work through the course before working as a volunteer; there was no formal clinical supervision in place at this site, however.

The two Incredible Years services (sites 2 and 3) were different in that, of all the sites, they had the most structured and formal arrangements for training and supervision. To deliver a programme, staff members were required to undergo formal training. Staff members were regularly supervised by local colleagues and there was ongoing monitoring from the programme base in the USA. The service lead explained why she thought the training and ongoing supervision and support were important:

We’re using an evidence-based programme and actually unless you really are delivering with fidelity we know that you can’t guarantee that you’re going to get the same results as [the] research . . . everybody who delivers the group in [area name] can be sure they’re either going to be able to work with [or get] supervision from someone who’s accredited either as a peer coach or as a mentor . . . I think that is really important in making it effective. These are hard groups to run, so it’s important ensuring that people do get the support. Service lead

Fidelity was not emphasised as strongly at any of the other sites. This is perhaps because fidelity can be in opposition to flexibility, a characteristic seen by many as a key factor in a service’s accessibility, as will become apparent when the next theme, Accessing self-care support , is discussed.

Integration with other services

As outlined earlier in the site descriptions, the two Incredible Years sites (sites 2 and 3) had been widely adopted by local commissioning bodies. These services were closely integrated with local planning and commissioning structures and with the local education, health and social services sectors. The Incredible Years services were an exception, however. None of the other services had this level of integration with health, education and social care. The family support service (site 4) was integrated in as much as it was run by a voluntary sector organisation but funded by a local authority, with clinical supervision provided by an NHS psychologist. It also had close links with special educational needs co-ordinators (SENCOs) in schools and could form part of an action plan arising from national ‘Common Assessment Framework’ 196 assessments. Staff at the family support service, however, perceived that there were overlaps between their work and that of the NHS and social services, and that they fitted into a niche between the two.

The self-harm group (site 1) was run from a NHS mental health trust, at a CAMH day service. The service is attached to an inpatient unit with residential and non-residential care and education provision. Self-harm groups using the same principles are run at other NHS locations in the region, and although these groups are integrated with other services to the extent that GPs and consultants can refer CYP to them, they are usually run as ‘standalone’ services with little integration with the NHS CAMHS provider delivering them. The eating disorders (site 5) and depression/anxiety (site 6) services were provided by charities dedicated to helping people with particular difficulties in these areas. The depression/anxiety service was run by a small, relatively new organisation which provided some other activities as well as the supported online CBT, and to some extent could be seen as an alternative, rather than a complement to, statutory services. Regarding the eating disorders charity operating at site 5, integration tended to be limited to ‘signposting’ in that message board posters often offered advice to other board users about how to access statutory services, encouraging users to overcome their anxieties in accessing such services and offering opinions about those services.

Where integration was most evident was in the referral processes at the various sites. This is discussed further in the next section.

Accessing self-care support

This theme, and the next, will present findings on the acceptability of the self-care support services, both in terms of their general accessibility (this theme) and the perceived attributes that services and their staff possess that facilitate CYP and their parents to care for themselves (the next theme). Regarding general accessibility, two key subthemes emerged from the data: one pertaining to referral and one focusing on engagement.

Referral to services

Children, young people and their families had accessed the services via a range of routes, including self-referral, signposting and referral by professionals. The self-harm (site 1), family support (site 4) and parenting group (site 3) services were well integrated into referral pathways and several CYP and parents at these sites had been referred in this way. Several postings on the eating disorders message boards (site 5) mentioned being ‘signposted’ to the board by health professionals, including psychologists and doctors. The parenting group (site 3) and anxiety/depression (site 6) sites encouraged self-referral and publicised their services; some parents had found out about the service through leaflets in their child’s school bag, or through a friend. The anxiety/depression site was advertised through posters and leaflets in shops and bars as well as through presentations at schools and Sure Start centres. At Dina School (site 2), staff at the school had approached the parents of children who they thought would benefit from the service and asked these parents for consent to include their children in the group. Schools were a common source of referrals for the family support service (site 4) and two children who participated in the study had been referred by school staff, one by a SENCO and one by a school nurse. The young person interviewed at the anxiety/depression site (site 6) had self-referred to this service following a presentation at school; in interview, the service manager expressed disappointment that no school nurses had made referrals to the service.

One family who had attended the family support service recalled a long wait (around 2 years) from becoming aware of the programme to the time when they started receiving the support. Waiting times were not cited as a problem, however, by other study participants.

Building and maintaining engagement

In building engagement with health-care services, one of the first barriers to overcome can be the physical access to services. The participants at all of the case study sites seemed to encounter few physical barriers to access, though it should be added that we did not recruit those with probably the best information about barriers to access – ‘dropouts’ from the services – to our sample. For the physically provided services, none of the CYP or parents reported particular problems with travel to the sites. The virtual eating disorders support site could be accessed via the internet at any time, although messages were only uploaded when staff members were available at the service to moderate them (until 20.30 on weekdays and until the afternoon on Saturdays). The Incredible Years services (sites 2 and 3) covered a large rural area and were provided in convenient venues across the region. The young people at the self-harm group site (site 1) were all at school or college and often had to miss school or college to attend the service, though none of the young people interviewed raised this as an issue. These young people were mostly brought by car to the service by their parents. There were several examples of staff working to make services convenient to attend, or taking the service to the families. For example, staff at the family support service (site 4) worked with families in their homes and with children at school. The parenting group (site 3) was generally provided in a group setting but could be run by staff on an individual basis at people’s homes if necessary:

Staff member: It’s very different to a traditional service where you might send out an invitation and if the parents don’t come then . . . they might say that you might not be able to access the service. With Incredible Years it’s more about going out and getting the parents really. So it’s about awareness raising, training lots of agencies who know about the programme . . . but [also] offering really nice coffee and biscuits. If parents miss a session, [it’s] really important that they have the hand-outs. So, if it’s possible, the leader goes and visits them at home.

Another staff member: Recently we’ve had a case [where] mum . . . is not ever there physically when we turn up for our appointment . . . so our worker . . . she’ll go to the child’s nursery . . . to try and catch mum at a drop-off, just to have that initial face-to-face engagement because we were mindful that this is a mum who is surrounded at the moment by professionals who are all breathing down her neck, and we wanted to make sure that mum had a fair view of where we were in that process, what our role is and that we’re not scary monsters who are trying to trip her up.

Flexibility in service provision seemed to be a key in not only building, but also maintaining, engagement with CYP and their families. As a member of staff at the family support service (site 4) outlines:

It’s looking at each case on an individual basis and thinking about what are the reasons for disengagement, why haven’t they engaged, is this a language issue, did they not understand when the appointment was, is it that the intervention isn’t working for them . . . It’s quite involved; but we don’t just do a kind of, if you don’t pitch up we send you a letter and then if you don’t pitch up again we bin you off to be picked up by some other agency – we will attempt always to get an answer. And then if it’s just that it’s not working, well, then we’ll have a conversation about that and let’s work it out. Staff member

Another example of the flexible nature of the services was the between-session support that the sites offered. At the self-harm (site 1), family support (site 4) and parenting group (site 3) sites, support in addition to the scheduled sessions was available, including staff being available to parents over the telephone if they wanted to make contact. Staff at these sites emphasised that they worked hard to engage people in the services and to maintain engagement once a supporting relationship had been established. However, a participant who provided clinical supervision at one of the sites provided an alternative perspective on this, suggesting that it was possible to be overly flexible in that, for example, always bringing the service to a family’s home could potentially discourage independence:

I think, the fact that they [the organisation] go out and work with families in their local area, either at home, or in schools . . . that’s really important . . . something that families will like [but] if you’re going to visit somebody at home then . . . how do you evaluate their motivation to change? Because . . . if you’re at home and somebody comes to see you then actually you don’t necessarily need to do anything to engage, other than sit and nod and make the right noises . . . but if you’ve actually got to physically leave the house and go somewhere, then that suggests that your motivation might be greater to engage . . . it’s trying to get the match between that initial buy in to the service [and maintaining engagement]. Staff member (from outside the organisation)

Some staff expressed an awareness of working with parents who were used to being highly monitored by statutory services and said this could sometimes be a challenge when working to engage parents initially. A school-based member of staff, for example, who had referred several children to the service observed:

You do have the odd family who you refer who don’t engage. And it’s very sad really . . . it’s usually . . . parents who have already got to the point of social services . . . [people think] oh, don’t get social services involved, they’ll take my children from me. And once social services are involved . . . they’re breathing down your neck all the time then, aren’t they? I mean, they’re popping in and out of your house all the time, they’re watching your every move, very intrusive. Staff member

Facilitating self-care support

This theme explores the perceived attributes that services and their staff possess that facilitate CYP and their parents to care for themselves. Key facilitators of mental health self-care support for CYP appear to be organisations and staff that are welcoming; a skills focus whereby CYP and parents are taught relevant self-care skills and then given the chance to practise these skills; opportunities for peer support; and the provision of time and attention.

Welcoming staff; welcoming organisations

Positive staff attitudes appeared to be particularly important. At every site (apart from the online eating disorders service), service users spoke spontaneously and positively about the staff running the service, using adjectives such as ‘nice’, ‘lovely’, ‘good’ and ‘thoughtful’ to describe them. Listening to CYP, allowing them to tell their own story and treating them with empathy and compassion, was also important. This was mentioned particularly by parents at the family support service (site 4) and the young people at the self-harm service (site 1), who liked the manner of the staff and contrasted this with previous, negative experiences at other services. Young people using the self-harm (site 1) and anxiety/depression (site 6) services in particular emphasised the importance of being able to trust staff in order to talk to them openly:

You have to feel comfortable talking to that person, if you don’t like them, then you’re not going to feel comfortable, so you’re not going to engage with them at the level that’s needed to help [you] recover. Young person

At several sites, CYP and parents perceived staff as wanting to understand and help them and felt that they were treated with care and compassion:

The service worker talked to me as if he’d been there before . . . went out of his way for me. Young person

It wasn’t just a job to her. Parent of a younger child

Knowing that the service would accept people for who they were and be open to hearing about their problems was an important attribute of the case study sites operated by voluntary sector organisations. Being non-judgemental or offering non-judgemental support was a particularly positive aspect:

You could be honest and say, ‘This is what my child has done’, and you weren’t judged. Parent of a younger child

Indeed, contrasts were sometimes drawn with other statutory or conventional health and social care services perceived (unfairly or not) as being judgemental. A worker who referred into the family support service noted:

You’ve got to the point where this has become . . . crisis time: ‘We’ve got a plan here in front of us, you will do this, you will do this, you will do this’ . . . whereas with [site name] it’s not, ‘you will do . . .’ it’s ’these are the suggestions that we can make, that will make things better for you’. So it’s not as judgemental, well, social services aren’t judgemental, I suppose, but it might feel like they are . . . I hear in lots of groups that I go to . . . ‘you’re all judging me, that I’m this, you’re judging me on that’. Staff member

A similar feeling was expressed in an interview with a young person at another site:

Young person: [With the general practitioner (GP) and] even with CAMHS sometimes . . . it seems a bit like I’m being judged, or it doesn’t seem like they’re there for me in the way that I’d like, but it was different with [site name], like, it definitely felt a lot more welcoming.

Interviewer: Okay. Is it the people at the GP and CAMHS? Or is it more general?

Young person: I think, it’s more the method, like, I mean, it’s just all about a feeling, it feels like if I’m at the doctors . . . it becomes a thing that I’m ill, or there’s something wrong with me . . . you still sit there and you feel like you’re being judged . . . it definitely affects your confidence when you’re trying to answer, like, the questions, like, confidently and with, like, full honesty . . . I don’t know, like, when I saw my GP I didn’t tell him the whole truth, just because I didn’t feel that comfortable.

Organisational features of the sites were also important in determining how welcoming a service was. In the earlier Service development and Building and maintaining engagement subthemes, we discussed how the service leads appeared to have a high level of leadership skills, and described how staff often worked hard to make services convenient to attend, or took the service directly to the families. There were also some comments about the premises that the services were delivered from. At two of the voluntary sector sites, staff explained that particular efforts had been made to ensure that the physical surroundings were attractive to young people, featuring, for example, bright colours and soft furnishings or having music playing. On the other hand, CYP at one site commented that the rooms in which the groups were held were somewhat small. The physical features of the premises, however, were overshadowed by spontaneous references that CYP and parents made to the welcoming ambience. Indeed, there was often blurring between organisational and individual staff attributes: ‘welcoming’, ‘friendly’ and ‘non-judgemental’ were used by CYP and parents to describe both the staff and the general atmosphere or ambience of the service, often in contrast to other services they had experienced.

Activities to build skills for self-care

The use of skill-building techniques and opportunities to practise such skills in their daily lives was considered an important feature of all six services. Children, young people and parents outlined a variety of practical activities and techniques, including games and exercises, which they had used in formal sessions (in vitro) as well as at home and in school (in vivo). Fittingly, given the nature of this study, most of these activities and techniques were designed to assist the participants in managing (self-managing) the CYP’s condition or problems. For example, in the self-harm group (site 1), young people were supported in devising coping strategies other than self-harming; in site 2, children practised communication skills at home that they had learnt at Dina School; and in the family support group (site 4), families were encouraged to action plan and set goals. For younger children in particular, a large proportion of their narratives consisted of their recollections of the various games and activities in which they had taken part. The youngest children stated that they had gone to Dina School to learn things and that they got ‘prizes’ (plastic chips) for doing well at the activities there:

Interviewer: And what did you get a chip for?

Child: When I’m doing stuff nice.

Many of these activities focused on identifying thoughts and emotions or on learning techniques to relieve anxiety or calm anger. These had been introduced by staff at the sites and also practised by children outside the sessions. The older primary school-aged children seemed to have more insight into the purpose of the activities and techniques:

We used to do these words about temper and then after that to calm me down we used to play a few games. Child

The parents who were interviewed also seemed to appreciate practical techniques and talked at length about implementing these at home. Reward systems including sticker charts were mentioned frequently, along with techniques designed to help children manage tasks and express their feelings:

I think it is important to have a task and try and complete it and stuff. Young person

I think she is responding well to positive rewards . . . she loves the reward charts . . . I give her a sticker just on her T-shirt if she’s done something really nice. Parent of younger child

And from an interview with another parent:

Interviewer: Are there any things in particular that you find helpful?

Parent of younger child: Well there was the words on the fridge . . . the fridge magnets spelling out, ‘I’m not happy’, ‘I’m . . .’

Child: ‘. . . sorry’.

Parent: ‘Sad’, ‘I’m sorry’ and . . .

Child: ‘I love you’.

Parent: ‘I love you’, yeah. We did that for a while. We lost all the pieces, like, we did it for a while.

Some games and techniques were ‘prescribed’ as part of the manual or workbook for the course. However, most of the activities allowed some personalisation such as tailoring rewards to the individual child. For example, staff at the family support service (site 4) found out what children were interested in or enjoyed and then looked for local activities or clubs they could join, such as football or the Boys’ Brigade. At the self-harm site (site 1), young people put together their own ‘tool boxes’ of distraction techniques, memorabilia and keepsakes that helped them reduce urges to self-harm. The service also provided support for caring for wounds that arose from cutting, and advice on ways to camouflage scars, with an organisation specialising in this visiting the group.

I’ve got this thing called a tool box in my room that I put all my different distraction techniques inside so, like, if I’m having a bad day, even if I’m not having a bad day . . . I could use the different things. And different things work at different times, so one time, like, writing out your feelings might be enough, or drawing might be enough, but sometimes you have to use a range of things to minimise that urge and sometimes nothing works, but . . . at least I’ve tried. Young person, interviewed with parent

The programmes delivered at sites 2 and 3 (the Incredible Years sites) and site 6 (the anxiety/depression support service) were supplemented by videos for participants to watch that contained vignettes or examples of role plays to augment the situations or techniques that the programmes considered. These were criticised repeatedly by staff and service users for being outdated and participants disliked that they had been filmed in the USA as they would have preferred British accents. One service user found them ‘idealised’ in that the actors looked too ‘perfect’ and suggested that videos featuring real people, not actors, would be more helpful.

Sharing experiences and peer support

Although a key aspect of all of the services at the case study sites was introducing CYP and their families to stock tools and techniques to help them care for themselves, an important aspect of skills building was supporting CYP and parents to discover self-care techniques for themselves. Often, this happened with the support of their peers, especially in the sites operating group-based approaches where other group members could play a key role in generating ideas or giving feedback. For example, children in the Dina School groups (site 2) took part in role plays and other interactions that helped them to think through how they could handle things that children might find difficult, such as sharing:

[Using a puppet to act out] snatching a book, [then discussing], is that kind?, is that unkind? . . . then after a while you’d get them to bring their problems in, you know, if you have a problem on the yard [playground], you know, if someone’s not listening to you, or doesn’t want to play, well, eventually they would come up [and talk about it with the group]. Staff member

Similarly, users of the online support service (site 5) frequently exchanged tips and techniques. Postings on the message boards often included users sharing self-care tips and suggestions with each other, and describing various relaxation or distraction techniques and activities such as reading, knitting, writing, drawing and exercising:

Listening to music is a huge relaxation thing for me, also drawing/writing – either a story, poetry or in a journal. Do you enjoy reading? To begin with i didnt have much concentration for reading, but now I am really enjoying reading again, and i find if i start reading after a meal when i am anxious that I can get lost in the book, and before i know it half an hour has passed. I’ve also tried knitting, but i’m a bit of a perfectionist so that didnt go so well. Hope you are ok, and that some of these tips may help you. Verbatim message board posting

The following were taken from two other sites:

They discuss coping strategies, like, they’ll say, like, if you get the urge to self-harm, what do you do? And they, sort of, come up with, ‘well, I’ll go and do this, I’ll go and put my favourite music on, my film, go for a walk, walk the dog, talk to my mum’ . . . and I do think it’s very beneficial. Staff member

I enjoyed the discussion. And what was nice is the feedback we gave each other . . . Because I think, that does you good, to have other people sometimes go, no, you’re good at that or why don’t you try this or why don’t you try that? . . . because you put it into practice with other people, it works better than you just reading books. Parent

Although the sharing of practical tips and techniques was an important element of peer support, the sharing of the experiences among CYP and parents was perhaps more beneficial. As discussed in the first theme, Having a mental health problem , some participants had not talked about their difficulties with other people prior to coming into the services and had felt alone with their problems. Staff members and attendees at several sites talked about the emotional benefit of being in a group with people who had had similar experiences, in that people who had previously felt isolated with their problems, or uncomfortable about seeking help for them, felt less alone:

It was actually amazing really; firstly because you realise that what your child was doing was normal and that all the other children were doing the same things. Parent of younger child

I think they listen more to their peers, their peers is pivotal, isn’t it, in adolescence, so I think the peer groups are very important, and that sense of belonging is good. And often . . . I’ve found that every single youngster who attends a group, is excluded from some aspect of their life, either from their family or from a peer group, because they’re bullied or they bully or, you know, they don’t fit somehow . . . So I guess being together with other young people helps you feel, you know, you’re not on your own with this. Staff member, another site

As well as receiving support from others, satisfaction gained from feeling that they had helped others was also important to some participants:

It was good for [my daughter] to see that she had helped other people, she liked that; that helped her as well. Parent of older child

As well as perceiving that the sharing of experiences was helpful, staff and parents felt that having a mixture of experiences and people at different stages of illness or recovery within a group provided additional benefits. The self-harm and parenting groups brought together people from different social groups who would normally not socialise together, but who had experienced similar problems, and this seemed to be helpful in terms of giving people a wider perspective on their problems, or perhaps developing empathy:

[They] have a good understanding of each other’s needs . . . it runs well because it’s a mixture . . . they’re all at different stages of their recovery . . . we’ve got young people who have been established for a long time and . . . have almost recovered, others are at the stage of contemplating, sort of, change and in the process of recovery and some that are not ready to change. And that’s, as I say, a very supportive group . . . those that are almost recovered, they do get and understand where [those who are less recovered] are coming from. Staff member

Very heterogeneous . . . you’d have youngsters in local authority care, and then you’d have very upper middle class young people, who were anxious about exams and stuff like that. And that actually works as well, because kind of sometimes it’s good to see people in other situations . . . you thought your situation was really bad, but actually, there’s people who are worse off, and something about that kind of gratitude about what you have got. Another staff member, same site

The participant quoted below, who described herself as ‘middle class and educated’ seemed to agree that this could be a benefit:

It sounds awful, but people that you might not necessarily have mixed with before, because you wouldn’t have had the chance, and got to know them . . . different social spheres . . . all of that’s broken down . . . [there can be perceptions that] . . . some backgrounds are better, supposedly, than others. And actually, you know, one of the mums in particular, who hadn’t got any further education . . . was just a fantastic mum. Whenever we’d . . . learn a new principle, when we’d feed back the next week, her and her partner had discussed it, and had both tried it . . . And it was nice to hear about other people, and there is a range of us, you know, people with partners, people without. Parent of younger child

The ‘sharing experiences’ aspect of peer support was complemented by others including the social aspect and what might be termed an ‘empowerment’ aspect. Regarding the social aspect, service users at the self-harm (site 1) and parenting (site 3) sites enjoyed attending the groups and especially liked the social aspect of getting to know others in the group. The parenting course (site 3) had an arranged ‘buddy system’ where parents were paired up and encouraged to telephone each other between sessions to talk about how they were getting on with their tasks or exercises, and some of these parents also reported forming friendships and continuing to meet socially after the programme had finished. From the focus group:

Young person 1: I prefer group talks, like, talking in groups, instead of taking medication . . . [at first] I was an inpatient so I was really struggling and . . . just having the support off people in the group was what I needed.

Young person 2: We’re good for each other!

Young person 3: We just, like, support people with what’s been going on in their week, and stuff, and it’s nice, because we’re like a little family.

Young person 4: We are like a family aren’t we?

The social benefit of groups was also reported by the staff member at the eating disorders message board service (site 5):

[T]he message board is a really good place to start forging links with other people in a very safe and supported way and it helps to build their confidence . . . when they suggest something to somebody [and they] come back and say, ‘that was really good, I did that and it really worked for me’ [they] make very strong bonds with each other. Staff member

Some of the group activities also appeared to help empower the CYP. For example, the self-harm groups (site 1) helped participants develop empathy by encouraging the young people to take it in turns to chair the group. Each group began with each member giving an update on how his or her week had been, and a role of the chair was to ensure that each person contributed. Staff observed that some young people in the group seemed unhappy or annoyed when they would have preferred not to contribute but the chairperson still asked them to share their experiences with the group. The staff member who described this thought that this could help young people to appreciate the difficult task that staff sometimes faced in encouraging young people to engage in ‘talking therapies’, and that sometimes encouraging someone to contribute in a group, even if they seemed not to want to, could help develop empathy and leadership skills in the young person.

Although our data demonstrate that peer support is beneficial, the risk of ‘contagion’, or triggering self-harm or problems with eating, was perceived as a key challenge by staff at the self-harm (site 1) and eating disorders (site 5) sites. Staff at both of these services saw risks in group work and worked actively to manage such risks. Unlike the parenting site (site 3), where parents were ‘buddied’ with another parent and encouraged to support each other between sessions, young people at other sites were discouraged from having contact outside of the service. At the self-harm site, young people were actively discouraged from meeting outside the group and, at the online site, interaction was controlled through moderation of the message board postings. This involved screening and editing posts to ensure that they did not contain contact information.

Some people who had attended the self-harm groups (site 1) and parenting courses (site 3) remembered feeling nervous about attending their first session. As it was the first time they had attended anything of that nature, they were unsure what to expect and were nervous about having to talk about their difficulties in front of other people. They felt that groups were only helpful for people who were at a stage of their illness or recovery where they were ready to attend a group. Our interviewees had all settled into the groups and had positive experiences, but they thought that the group setting would not be suitable for everyone; some people simply would not want or choose to discuss their problems in a group setting. Staff at the self-harm group identified managing dominant personalities as a further challenge that they had to be aware of, in order to make sure that all group members had a chance to participate during each session.

Time and attention

Giving CYP time and attention appeared to be a valued characteristic of the services. At four of the six sites, participants valued simply spending time with children, especially when this involved enjoyable activities. A key principle of Dina School (site 2) and the parenting course (site 3) was giving children positive attention. The Dina School groups allowed for each child to receive more attention than would be possible in a regular class. Parents felt that their children enjoyed being in the group and that the environment was more realistic than the regular classroom for them to learn about talking about their feelings. Parents who attended the parenting course found that setting time aside for their children was helpful, including scheduling time to play with them and also having activities together as a reward for good behaviour, and reported that their children were calmer. At the family support service (site 4), a worker described how during school holidays, instead of having appointments with children at their school, she had collected them from home and brought them to the centre, and had been surprised by how much they enjoyed this:

Often I’ll go and pick the children up and bring them here, which they just think is the best thing in the world . . . it’s not that exciting, but it’s just something different . . . that’s what some of them say. Staff member

Participants of different ages seemed to enjoy positive attention, perhaps away from a school or the clinical or home environment:

Another thing as well that sticks in my mind about the group is when [staff member] actually took us out once into town . . . as a group . . . just to do something nice, instead of being stuck in a small room that’s quite clinical . . . it was good. Young person

At one site, young people recalled their experiences of being inpatients, when some staff would come to talk to them, but often at inappropriate times or not for long enough. At another, family members of younger children appreciated project workers talking to the children themselves.

I think that young people often really have appreciated the fact that someone has taken the time to listen to them and hear their side of the story. Staff member

An older sibling of one of the children at the same service singled out the way that the project worker had helped her brother to understand his behaviours and the emotions attached to them, and what might affect these:

When [child’s name] used to get angry we used to talk to him and try and calm him down . . . but we never used to speak to him about why he got angry . . . I think because [project worker’s name] spoke to him and broke it down into steps that he could understand . . . and then she used to ask him stuff about his friends and his family. Sibling

Although CYP and parents appreciated the time and attention that staff at the sites gave them, staff mentioned that operational constraints sometimes prevented them from providing as much time as they would have liked. The manuals for the Incredible Years services (sites 2 and 3, Dina School and parenting groups) were prescriptive, with themes and associated activities being set out for each session. However, although staff at these sites liked the fact that all the materials for the sessions, and also the letters to send home to parents, were provided (as this made the course easy to deliver), they felt that there was too great a volume of material, and that they had often had to leave out certain aspects in order to complete the sessions on time.

Sometimes it was hard to keep their attention, because we’ve got a programme to deliver and it’s quite a lot to fit into those 2 hours, so sometimes [we] would look at it before and think we’re never going to fit all that in so we’d think, right, we won’t do that activity today, we’ll do that next week and try to fit in an activity where they’d be moving a bit more and try to adapt it a little bit. Staff member

Both CYP and parent participants at several sites mentioned that they would have preferred more sessions or time with the service – a statement also echoed by staff at some sites – but financial constraints prevented this from occurring. In particular, staff at one of the voluntary sector sites outlined how a scheduled 15-week programme had to be reduced to 12 weeks because of financial and resource restraints.

Now we have this 12-week programme and it used to be a bit more like 15 weeks and we used to be able to be a bit more flexible with what each different family needed . . . I feel I used to do a lot more . . . therapeutic work with the young people and creative work, and some of that has had to be cut because we’re having to be a bit more focused on where we need to get to, which is a bit of a shame . . . I used to do a lot more kind of crafty things . . . than I feel that I’ve got the time to really do now. Staff member

• Summary of the case study findings

This chapter has presented the findings derived from 52 interviews with children, young people, parents and staff, some documentary evidence and over 500 message board postings at six case study sites.

The aim of this stage of the project was to investigate the acceptability of mental health self-care support services for CYP and the interface between mental health self-care support providers, the NHS and other service providers in the statutory, private and voluntary sectors.

A common feature across all the case study sites was the perceived accessibility of the services provided. The self-care support services appeared to offer convenient locations and appointment times, maintained engagement with between-session support, and were staffed by people who were caring and compassionate. Given that self-care support necessarily requires an agent – a professional or lay person to provide that support – it was reassuring to witness passionate, motivated, welcoming, non-judgemental and child-centred staff at all six sites. Where barriers were mentioned, they tended to be discussed in the context of other, sometimes competing, services (including standard NHS and local authority services) rather than with reference to the services at the six sites. These barriers could be seen as criticisms of the other sites and were broadly related to inflexibility: applying (stigmatising) diagnoses and labels, rather than seeing the child or young person as a person needing help and support; being dismissive of, or failing to appreciate, the concerns that CYP and their families might have about having a ‘mental health problem’ or accessing services; adhering rigidly to manualised interventions without questioning the readiness of CYP and their families to self-care or the intervention’s suitability to the CYP; and affording them little choice in their (self-)care.

Taking all of the participants’ perspectives – CYP, parents and staff – into account, we can speculate on some of the key elements of effective mental health self-care support for CYP. From the case study data it seems that, in addition to flexibility, effective mental health self-care support services for CYP seem to be built on straightforward access; positive staff and organisational attributes that are non-judgemental and welcoming; the provision of time and attention; the chance to learn and practise skills relevant to self-care; and systems of peer support which include opportunities to share experiences and practical tips.

If there is an overall constraint, it is regarding the interface with other services. The case study sites cut across the NHS, other statutory providers and the voluntary sector, yet there was no clear pattern of how well these providers worked together, if at all. In the two Incredible Years sites, there was a seamless integration of the health, social care and education sectors; yet in another site (the family support group), even though there was ‘nominal’ integration between health, social care and education, the service preferred to see itself as a ‘niche’ not quite fitting into any of these domains. In the other sites, there was either no visible integration or somewhat erratic integration or, as in the case of one site, an almost defiant refusal to integrate demonstrated by the setting up of an alternative, rather than complementary, service. Where the interface between the sectors worked best was in relation to referral: though only a few services had extremely well-integrated referral pathways, all had some degree of interface, even if it was as simple as merely signposting into, or out of, the self-care support service, or using networks among the sectors to promote self-referral to the service.

Included under terms of UK Non-commercial Government License .

• Cite this Page Pryjmachuk S, Elvey R, Kirk S, et al. Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study. Southampton (UK): NIHR Journals Library; 2014 Jun. (Health Services and Delivery Research, No. 2.18.) Chapter 5, The case study.
• PDF version of this title (3.8M)

In this Page

Other titles in this collection.

• Health Services and Delivery Research

Recent Activity

• The case study - Developing a model of mental health self-care support for child... The case study - Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

Recommended pages

• Undergraduate open days
• Postgraduate open days
• Accommodation
• Information for teachers
• Maps and directions
• Sport and fitness

Mental health practice case studies

Each of these short films presents a case study of a potentially difficult mental health situation that practitioners may need to deal with as part of their practice. Topics covered include appropriate listening skills, confidentiality, drug use, professional conduct, anger, social isolation, sexual advances and stereotyping. The aim of these films is to stimulate discussion and reflection about these particular situations and the issues that arise from them.

The following group of case studies form part of the Online Assessment Workbook.

See also Mental health case studies which were filmed as part of the SELF Project.

Return to film Index

A sample case study: Mrs Brown

On this page, social work report, social work report: background, social work report: social history, social work report: current function, social work report: the current risks, social work report: attempts to trial least restrictive options, social work report: recommendation, medical report, medical report: background information, medical report: financial and legal affairs, medical report: general living circumstances.

This is a fictitious case that has been designed for educative purposes.

Mrs Beryl Brown URN102030 20 Hume Road, Melbourne, 3000 DOB: 01/11/33

Date of application: 20 August 2019

Mrs Beryl Brown (01/11/33) is an 85 year old woman who was admitted to the Hume Hospital by ambulance after being found by her youngest daughter lying in front of her toilet. Her daughter estimates that she may have been on the ground overnight. On admission, Mrs Brown was diagnosed with a right sided stroke, which has left her with moderate weakness in her left arm and leg. A diagnosis of vascular dementia was also made, which is overlaid on a pre-existing diagnosis of Alzheimer’s disease (2016). Please refer to the attached medical report for further details.

I understand that Mrs Brown has been residing in her own home, a two-story terrace house in Melbourne, for almost 60 years. She has lived alone since her husband died two years ago following a cardiac arrest. She has two daughters. The youngest daughter Jean has lived with her for the past year, after she lost her job. The eldest daughter Catherine lives on the Gold Coast with her family. Mrs Brown is a retired school teacher and she and both daughters describe her as a very private woman who has never enjoyed having visitors in her home. Mrs Brown took much encouragement to accept cleaning and shopping assistance once a week after her most recent admission; however, she does not agree to increase service provision. Jean has Enduring Power of Attorney (EPOA) paperwork that indicates that Mrs Brown appointed her under an EPOA two years ago. She does not appear to have appointed a medical treatment decision maker or any other decision-supporter.

I also understand from conversations with her daughters that Jean and Mrs Brown have always been very close and that there is a history of long-standing conflict between Catherine and Jean. This was exacerbated by the death of their father. Both daughters state they understand the impact of the stroke on their mother’s physical and cognitive functioning, but they do not agree on a discharge destination. Mrs Brown lacks insight into her care needs and says she will be fine once she gets back into her own home. Repeated attempts to discuss options with all parties in the same room have not resulted in a decision that is agreeable to all parties.

Mrs Brown has a history of Alzheimer’s disease; type II diabetes – insulin dependent; hypertension; high cholesterol and osteoarthritis. She has had two recent admissions to hospital for a urinary tract infection and a fall in the context of low blood sugars. She is currently requiring one to two people to assist her into and out of bed and one person with managing tasks associated with post-toilet hygiene. She can walk slowly for short distances with a four-wheel frame with one person to supervise. She benefits from prompting to use her frame; she needs someone to cut her food and to set her up to eat and drink regularly and to manage her medication routine. She requires one person to assist her to manage her insulin twice daily.

The team believe that Mrs Brown’s capacity for functional improvement has plateaued in the last ten days. They recommend that it is in her best interests to be discharged to a residential care setting due to her need for one to two people to provide assistance with the core tasks associated with daily living. Mrs Brown is adamant that she wants to return home to live with Jean who she states can look after her. Jean, who has a history of chronic back pain, has required several admissions to hospital over the past five years, and states she wants to be able to care for her mother at home. Jean states she is reluctant to agree to extra services as her mother would not want this. Her sister Catherine is concerned that Jean has not been coping and states that given this is the third admission to hospital in a period of few months, believes it is now time for her mother to enter residential care. Catherine states that she is very opposed to her mother being discharged home.

Mrs Brown is at high risk of experiencing falls. She has reduced awareness of the left side of her body and her ability to plan and process information has been affected by her stroke. She is now requiring one to two people to assist with all her tasks of daily living and she lacks insight into these deficits. Mrs Brown is also at risk of further significant functional decline which may exacerbate Jean’s back pain. Jean has stated she is very worried about where she will live if her mother is to enter residential care.

We have convened two family meetings with Mrs Brown, both her daughters and several members of the multi-disciplinary team. The outcome of the first meeting saw all parties agree for the ward to provide personalised carer training to Jean with the aim of trialling a discharge home. During this training Jean reported significant pain when transferring her mother from the bed and stated she would prefer to leave her mother in bed until she was well enough to get out with less support.

The team provided education to both Jean and Catherine about the progressive impact of their mother’s multiple conditions on her functioning. The occupational therapist completed a home visit and recommended that the downstairs shower be modified so that a commode can be placed in it safely and the existing dining room be converted into a bedroom for Mrs Brown. Mrs Brown stated she would not pay for these modifications and Jean stated she did not wish to go against her mother’s wishes. The team encouraged Mrs Brown to consider developing a back-up plan and explore residential care options close to her home so that Jean could visit often if the discharge home failed. Mrs Brown and Jean refused to consent to proceed with an Aged Care Assessment that would enable Catherine to waitlist her mother’s name at suitable aged care facilities. We proceeded with organising a trial overnight visit. Unfortunately, this visit was not successful as Jean and Catherine, who remained in Melbourne to provide assistance, found it very difficult to provide care without the use of an accessible bathroom. Mrs Brown remains adamant that she will remain at home. The team is continuing to work with the family to maximise Mrs Brown’s independence, but they believe that it is unlikely this will improve. I have spent time with Jean to explore her adjustment to the situation, and provided her with information on community support services and residential care services. I have provided her with information on the Transition Care Program which can assist families to work through all the logistics. I have provided her with more information on where she could access further counselling to explore her concerns. I have sought advice on the process and legislative requirements from the Office of the Public Advocate’s Advice Service. I discussed this process with the treating team and we decided that it was time to lodge an application for guardianship to VCAT.

The treating team believe they have exhausted all least restrictive alternatives and that a guardianship order is required to make a decision on Mrs Brown’s discharge destination and access to services. The team recommend that the Public Advocate be appointed as Mrs Brown’s guardian of last resort. We believe that this is the most suitable arrangement as her daughters are not in agreement about what is in their mother’s best interests. We also believe that there is a potential conflict of interest as Jean has expressed significant concern that her mother’s relocation to residential care will have an impact on her own living arrangements.

Mrs Brown’s medical history includes Alzheimer’s disease; type II diabetes; hypertension; high cholesterol and osteoarthritis. She was admitted to Hume Hospital on 3 March 2019 following a stroke that resulted in moderate left arm and leg weakness. This admission was the third hospital admission in the past year. Other admissions have been for a urinary tract infection, and a fall in the context hypoglycaemia (low blood sugars), both of which were complicated by episodes of delirium.

She was transferred to the subacute site under my care, a week post her admission, for slow-stream rehabilitation, cognitive assessment and discharge planning.

Mrs Brown was diagnosed with Alzheimer’s disease by Dr Joanne Winters, Geriatrician, in April 2016. At that time, Mrs Brown scored 21/30 on the Standardised Mini-Mental State Examination (SMMSE). During this admission, Mrs Brown scored 15/30. I have undertaken cognitive assessment and agree with the diagnosis; further cognitive decline has occurred in the context of the recent stroke. There are global cognitive deficits, but primarily affecting memory, attention and executive function (planning, problem solving, mental flexibility and abstract reasoning). The most recent CT-Brain scan shows generalised atrophy along with evidence of the new stroke affecting the right frontal lobe. My assessments suggest moderate to severe mixed Alzheimer’s and vascular dementia.

While able to recall some key aspects of her financial affairs, including the general monetary value of her pension and regular expenses, Mrs Brown was unable to account for recent expenditure (for repairs to her home) or provide an estimate of its value, and had difficulty describing her investments. In addition, I consider that she would be unable to make complex financial decisions due to her level of cognitive impairment. Accordingly, I am of the view that Mrs Brown now lacks capacity to make financial decisions.

Mrs Brown states that she previously made an Enduring Power of Attorney (EPOA) but could no longer recall aspects of the EPOA, such as when it would commence and the nature of the attorney’s powers. Moreover, she confused the EPOA with her will. Her understanding of these matters did not improve with education, and therefore I consider that she no longer has capacity to execute or revoke an EPOA.

Mrs Brown acknowledges that she needs some assistance but lacks insight into the type of assistance that she requires, apart from home help for cleaning and shopping. She does not appreciate her risk of falling. She is unable to get in and out of bed without at least one person assisting her. She frequently forgets to use her gait aid when mobilising and is not able to describe how she would seek help in the event of falling. She is not able to identify or describe how she would manage her blood sugar levels, and this has not improved with education. Accordingly, I consider that she lacks capacity to make decisions about accommodation arrangements and services.

Mrs Brown does not agree with the treating team’s recommendation to move into residential care and maintains her preference to return home. This is in spite of a failed overnight trial at home with both her daughters assisting her. Unfortunately, she was unable to get out of bed to get to the toilet and required two people to assist her to do so in the morning. In light of these matters, and in the context of family disagreement regarding the matter, the team recommends that the Office of the Public Advocate be appointed as a guardian of last resort.

Reviewed 22 July 2022

• Hospitals & health services
• Public hospitals in Victoria
• Patient care
• Ambulance and patient transport
• Non-emergency patient transport
• Non-emergency patient transport review
• NEPT legislation and clinical practice protocols
• Non-emergency patient transport licensing
• NEPT licensing fees
• NEPT services information and guidance
• First Aid Services
• First aid licences
• First aid services information and guidance
• First aid service fees
• Victorian State Trauma System
• Acute medicine
• Emergency care
• Surgical services
• Better at Home
• Critical care
• Hospital in the Home
• Virtual care (Telehealth)
• Perinatal and reproductive services
• Rehabilitation and complex care
• Renal health
• Renal services in Victoria
• Funding for renal services
• Different approaches to haemodialysis
• Specialist clinics
• Access to non-admitted services
• Minimum referral information
• Communication toolkit
• Integrated care
• HealthLinks: Chronic Care
• Community Health Integrated Program (CHIP) guidelines
• Service coordination in Victoria
• Victorian integrated care online resources
• Specialist clinics programs
• Specialist clinics reform
• Specialty diagnostics, therapeutics and programs
• Older people in hospital
• End of life and palliative care in Victoria
• Voluntary assisted dying
• Quality, safety and service improvement
• Planned surgery recovery and reform program
• Digital Health
• Roadmap and Maturity Model
• Standards and guidelines
• Policies and frameworks
• Health Information Sharing Legislation Reform
• My Health Record
• Public hospital accreditation in Victoria
• Credentialing for senior medical staff in Victoria
• Clinical risk management
• Preventing infections in health services
• Healthy choices
• Victorian Perinatal Data Collection
• Rural health
• Improving Access to Primary Care in Rural and Remote Areas Initiative
• Rural x-ray services
• Rural health regions and locations
• Rural and regional medical director role
• Victorian Patient Transport Assistance Scheme
• Rural and isolated practice registered nurses
• Urgent care in regional and rural Victoria
• Private health service establishments
• Private hospitals
• Day procedure centres
• Mobile health services
• Fees for private health service establishments in Victoria
• Design resources for private health service establishments
• Professional standards in private health service establishments
• Legislation updates for private health service establishments
• Complaints about private health service establishments
• Cosmetic procedures
• Guideline for providers of liposuction
• Private hospital funding agreement
• Boards and governance
• About health service boards in Victoria
• Information and education
• Education resources for boards
• Sector leadership
• Data, reporting and analytics
• Health data standards and systems
• Funding, performance and accountability
• Statements of Priorities
• Performance monitoring framework
• Integrity governance framework and assessment tool
• Pricing and funding framework
• Patient fees and charges
• Fees and charges for admitted patients
• Non-admitted patients - fees and charges
• Other services
• Planning and infrastructure
• Sustainability in Healthcare
• Medical equipment asset management framework
• Health system design, service and infrastructure planning
• Complementary service and locality planning
• Primary & community health
• Primary care
• Community pharmacist pilot
• EOI - Victorian Community Pharmacist Statewide Pilot
• Victorian Community Pharmacist Statewide Pilot – Resources for pharmacists
• Emergency Response Planning Tool
• Working with general practice
• Victorian Supercare Pharmacies
• NURSE-ON-CALL
• Priority Primary Care Centres
• Local Public Health Units
• Community health
• Community health services
• Community health pride
• Registration and governance of community health centres
• Community Health Directory
• Community Health Program in Victoria
• Community health population groups
• Dental health
• Access to public dental care services
• Victoria's public dental care fees
• Victoria's public dental care waiting list
• Dental health for SRS residents
• Dental health program reporting
• Smile Squad school dental program
• Maternal and Child Health Service
• Nursery Equipment Program
• Maternal and Child Health Service Framework
• Maternal and Child Health Service resources
• Child Development Information System
• Early parenting centres
• Maternal Child and Health Reporting, Funding and Data
• Baby bundle
• Sleep and settling
• Maternal and Child Health Workforce professional development
• Aboriginal Maternal and Child Health
• Public Dental and Community Health Program funding model review
• Public health
• Women's Health and Wellbeing Program
• Inquiry into Women's Pain
• Inquiry into Women's Pain submissions
• Support groups and programs
• About the program
• Victorian Women's Health Advisory Council
• Cemeteries and crematoria
• Cemetery trust member appointments
• Cemetery search
• Cemeteries and crematoria complaints
• Exhumations
• Governance and finance
• Cemetery grants
• Interments and memorials
• Land and development
• Legislation governing Victorian cemeteries and crematoria
• Cemeteries and crematoria publications
• Repatriations
• Rights of interment
• Medicines and Poisons Regulation
• Patient Schedule 8 treatment permits
• Schedule 8 MDMA and Schedule 8 psilocybine
• Schedule 9 permits for clinical trials
• Documents and forms to print or download
• Legislation and Approvals
• Frequently Asked Questions - Medicines and Poisons Regulation
• Health practitioners
• Licences and permits to possess (& possibly supply) scheduled substances
• Medicinal cannabis
• Pharmacotherapy (opioid replacement therapy)
• Recent updates
• Environmental health
• Improving childhood asthma management in Melbourne's inner west
• Climate and weather, and public health
• Environmental health in the community
• Environmental health in the home
• Environmental health professionals
• Face masks for environmental hazards
• Human health risk assessments
• Lead and human health
• Per- and poly-fluoroalkyl substances (PFAS)
• Pesticide use and pest control
• Food safety
• Information for community groups selling food to raise funds
• Food businesses
• Food safety information for consumers
• Food regulation in Victoria
• Food safety library
• Food allergens
• Introducing Standard 3.2.2A: Food safety management tools
• Immunisation
• Respiratory syncytial virus (RSV) immunisation
• Seasonal influenza vaccine
• Immunisation schedule and vaccine eligibility criteria
• Ordering vaccine
• Immunisers in Victoria
• Immunisation provider information
• Cold chain management
• Adverse events following immunisation reporting
• Vaccine error management
• Vaccination for infants and children
• Vaccination for adolescents
• Vaccination program for adults
• Vaccination for special-risk groups
• Immunisation resources order form
• Victorian coverage rates for Victoria
• Infectious diseases guidelines & advice
• Infection control guidelines
• Disease information and advice
• Advice to the cruise industry: reporting infections
• Notifiable infectious diseases, conditions and micro-organisms
• Notification procedures for infectious diseases
• Infectious diseases surveillance in Victoria
• Germicidal ultraviolet light
• Protecting patient privacy in Victoria
• Population health systems
• Evidence and evaluation
• Health promotion
• Health status of Victorians
• Municipal public health and wellbeing planning
• Population screening
• Cancer screening
• Conditions not screened
• Improving outcomes in under-screened groups
• Infant hearing screening
• Newborn bloodspot screening
• Prenatal screening
• Screening registers
• Preventive health
• Type 2 diabetes and cardiovascular disease prevention
• Eye health promotion
• Injury prevention
• Healthy eating
• Oral health promotion
• Physical activity
• Sexual health
• Sex worker health
• Decriminalisation of sex work
• Automatic mutual recognition
• Domestic smoke detectors
• Lasers, IPL and LED devices for cosmetic treatments and beauty therapy
• Victoria's regulatory framework for radiation
• Radiation newsletter
• Tobacco reforms
• Tobacco reform legislation and regulations
• E-cigarettes and vaping
• Quitting smoking and vaping
• Smoke-free and vape-free areas
• Building entrances
• Children's indoor play centres
• Public hospitals and health centres
• Children's recreational areas
• Playground equipment
• Skate parks
• Swimming pools
• Under-age sporting events
• Enclosed workplaces
• Government buildings
• Learning environments
• Outdoor dining
• Outdoor drinking areas
• Patrolled beaches
• Train platforms and bus and tram shelters
• Under-age music or dance events
• Tobacco and e-cigarette retailers
• Making a report or complaint
• Resources and factsheets
• Alternative water supplies
• Aquatic facilities
• Blue-green algae (cyanobacteria)
• Drinking water in Victoria
• Legionella risk management
• Private drinking water
• Recreational water use and possible health risks
• Water fluoridation
• Chief Health Officer
• About the Chief Health Officer
• Chief Health Officer publications
• Health alerts and advisories
• Mental health
• Mental Health and Wellbeing Act 2022
• Mental Health and Wellbeing Act 2022 Handbook
• Community information
• Mental Health and Wellbeing Act 2022 in your language
• About Victoria's mental health services
• Area-based services
• Statewide and specialist mental health services
• Mental Health Community Support Services
• Support and intervention services
• Language services - when to use them
• Access to mental health services across areas
• Transport for people in mental health services
• Practice and service quality
• Medical Treatment Planning and Decisions Act
• Service quality
• Specialist responses
• Mental health and wellbeing reform
• Reform activity updates
• Priority areas
• Latest news
• Working with consumers and carers
• Consumer and carer engagement
• Consumer and Carer Experience Surveys
• Family support and crisis plans
• Consumer and carer financial support
• Supporting children whose parents have a mental illness
• Supporting parents with a mental illness
• Prevention and promotion
• Early intervention in mental illness
• Mental health promotion in Victoria
• Suicide prevention in Victoria
• Priorities and transformation
• Supporting the social and emotional wellbeing of Aboriginal and Torres Strait Islander Victorians
• National mental health strategy
• Rights and advocacy
• Making a complaint about a mental health service
• Chief Psychiatrist
• About the Chief Psychiatrist
• Principles in the Mental Health and Wellbeing Act and the Chief Psychiatrist's guidelines
• Obligations under the Mental Health and Wellbeing Act 2022
• Reporting a failure to comply with the Mental Health and Wellbeing Act 2022
• Governance and committees
• Reporting obligations for clinical mental health and wellbeing services
• Mental health and wellbeing support
• Making a complaint and seeking advocacy
• Second psychiatric opinion and process of review by Chief Psychiatrist
• Office of the Chief Psychiatrist's reform activities and news
• Oversight of forensic mental health and wellbeing services
• Resources and reports
• Chief psychiatrist guidelines
• Chief Mental Health Nurse
• About Victoria's Chief Mental Health Nurse
• Best practice
• Reducing restrictive interventions
• Research and reporting
• Mental health performance reports
• Reporting requirements and business rules for clinical mental health services
• Alcohol & drugs
• Alcohol and other drug treatment services
• Overview of Victoria's alcohol and drug treatment system
• Pathways into alcohol and other drugs treatment
• Prevention and harm reduction
• Medically supervised injecting room
• Victoria's Take-Home Naloxone Program
• Community-based AOD treatment services in Victoria
• Residential treatment services
• Mildura statewide alcohol and drug residential treatment service
• Drug rehabilitation plan
• Hospital-based services
• Forensic services
• Pharmacotherapy treatment
• Services for Aboriginal people
• Services for young people
• Statewide and specialist services
• Compulsory treatment
• Family and peer support
• Public intoxication reform
• New public intoxication response services
• Policy, research and legislation
• Alcohol and drug research and data
• Legislation governing alcohol and other drug treatment
• Alcohol and other drug service standards and guidelines
• Alcohol and other drug client charter and resources
• Alcohol and other drug treatment principles
• Service quality and accreditation
• Alcohol and other drug program guidelines
• Maintenance pharmacotherapy
• Specialist Family Violence Advisor capacity building program in mental health and alcohol and other drug services - Victoria
• Alcohol and other drug workforce
• Learning and development
• Alcohol and other drug workforce Minimum Qualification Strategy
• Workforce data and planning
• Funding and reporting for alcohol and other drug services
• Funding of alcohol and other drugs services in Victoria
• Reporting requirements and business rules for alcohol and other drug services
• Drug alerts
• 25C-NBOMe and 4-FA sold as '2C-B'
• Novel stimulants sold as MDMA, cocaine or speed
• Protonitazene sold as ketamine
• High potency benzodiazepine tablets
• MDMA adulterated with PMMA
• 25B-NBOH sold as powdered 'LSD'
• Green 'UPS' pills containing N-ethylpentylone (no MDMA)
• N-ethylpentylone in cocaine
• Ageing & aged care
• Supporting independent living
• Low cost accommodation support programs
• Personal Alert Victoria
• Dementia services
• Victorian Aids and Equipment Program
• Residential aged care services
• Public sector residential aged care services
• Safety and quality in public sector residential aged care
• Physical and social environments
• Emergency preparedness in residential aged care services
• My Aged Care assessment services
• Home and Community Care Program for Younger People
• HACC data reporting
• HACC PYP fees policy and schedule of fees
• Wellbeing and participation
• Age-friendly Victoria
• Healthy ageing
• Seniors participation
• Dementia-friendly environments
• Designing for people with dementia
• Maintaining personal identity
• Personal enjoyment
• Interior design
• Dining areas, kitchens and eating
• Bedrooms and privacy
• Gardens and outdoor spaces
• Assistive technology
• Staff education and support
• Strategies, checklists and tools
• Our Strategic Plan 2023-27
• Our organisation
• Our secretary
• Leadership charter
• Our services
• Our vision and values
• Specialist offices
• Senior officers in health
• Human Research Ethics Committee (HREC)
• Gifts, benefits and hospitality policy
• Information Asset Register
• Health legislation
• Health legislation overview
• Health Complaints legislation
• Health Records Act
• Human Tissue Act 1982
• Public Health and Wellbeing Act 2008
• Voluntary Assisted Dying Act
• Victoria's pandemic management framework
• Independent Pandemic Management Advisory Committee
• Pandemic Order Register
• Our ministers
• Our role in emergencies
• State Health Emergency Response Arrangements
• Emergency type
• Department's responsibilities in emergencies
• Health services’ responsibilities in emergencies
• Aboriginal employment
• Current vacancies
• Employment programs for students and graduates
• Rise program
• Inclusion and diversity at the Department of Health
• Health workforce
• Working in health
• Information sharing and MARAM
• Child Safe Standards
• Regulatory functions
• Reviews of decisions
• Victorian Public Healthcare Awards
• Aboriginal healthcare workers
• Mental health workforce
• Lived and living experience workforces
• Engaging with lived and living experience workforces
• Our workforce, our future
• Nursing and midwifery
• Free nursing and midwifery study
• Additional funding for nursing and midwifery positions
• Becoming a nurse or midwife
• Undergraduate nursing and midwifery scholarships
• Undergraduate student employment programs
• Nursing and midwifery graduates
• Nursing and midwifery graduate sign-on bonus
• Working as a nurse or midwife
• Enrolled nurse to registered nurse transition scholarships
• Support for new nurse practitioners
• Postgraduate scholarships for nurses and midwives
• Nurse practitioners
• Returning to nursing or midwifery
• Refresher pathway for nurses and midwives
• Re-entry pathway scholarships for nurses and midwives
• Nursing and midwifery - legislation and regulation
• Nursing and midwifery program - health sector
• Allied health workforce
• Education and training
• Enterprise agreements
• Worker health and wellbeing
• Working with us
• Grants and programs
• Freedom of Information
• Part II - Information Statements
• Procurement policies
• Protective markings
• Health and medical research
• Sponsorship application information
• Publications
• Annual reports
• Fact sheets
• Strategies, plans and charters
• Policies, standards and guidelines
• Research and reports
• Forms and templates
• Communities
• Designing for Diversity
• Vulnerable children
• Vulnerable children - responsibilities of health professionals
• Identifying and responding to children at risk
• Pathway to good health for children in care
• Older people
• Aboriginal health
• Improving health for Victorians from culturally and linguistically diverse backgrounds
• Asylum seeker and refugee health in Victoria
• News and media hub
• Media releases
• Health alerts
• Feedback and complaints
• Make a payment
• Fees, charges and penalties subject to automatic indexation
• Our campaigns

Share this page

• Facebook , opens a new window
• X (formerly Twitter) , opens a new window
• LinkedIn , opens a new window

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• My Account Login
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 26 May 2024

Effects of expanded adverse childhood experiences including school bullying, childhood poverty, and natural disasters on mental health in adulthood

• Natsu Sasaki 1 ,
• Kazuhiro Watanabe 2 ,
• Yoshiaki Kanamori 3 ,
• Takahiro Tabuchi 4 , 5 ,
• Takeo Fujiwara 6 &
• Daisuke Nishi 1  

Scientific Reports volume  14 , Article number:  12015 ( 2024 ) Cite this article

333 Accesses

2 Altmetric

Metrics details

• Medical research
• Risk factors

The study aimed to examine the association of expanded adverse childhood experiences (ACEs) with psychological distress in adulthood. The data from nation-wide online cohort was used for analysis. Community dwelling adults in Japan were included. The ACEs was assessed by 15 items of ACE-J, including childhood poverty and school bullying. Severe psychological distress was determined as the score of Kessler 6 over 13. Multivariable logistic regression analysis was conducted, by using sample weighting. A total of 28,617 participants were analyzed. About 75% of Japanese people had one or more ACEs. The prevalence of those with ACEs over 4 was 14.7%. Those with ACEs over 4 showed adjusted odds ratio = 8.18 [95% CI 7.14–9.38] for severe psychological distress. The prevalence of childhood poverty was 29% for 50–64 year old participants and 40% of 65 or older participants. The impact of childhood poverty on psychological distress was less than other ACEs in these age cohorts. Bullying was experienced 21–27% in young generations, but 10% in 65 or older participants. However, the impact on psychological distress in adulthood was relatively high in all age groups. ACEs have impacted mental health for a long time. Future research and practice to reduce ACEs are encouraged.

Similar content being viewed by others

Specific adverse childhood experiences and their association with other adverse childhood experiences, asthma and emotional, developmental and behavioral problems in childhood

Neural vulnerability and hurricane-related media are associated with post-traumatic stress in youth

Identifying adverse childhood experiences in pediatrics to prevent chronic health conditions

Introduction.

Adverse childhood experiences (ACEs) are traumatic events that children and adolescents under 18 years of age have experienced 1 . People with a history of ACEs are at greater risk of deterioration in physical and mental health 2 , 3 , and ultimately premature mortality 4 , 5 . The cumulative effect of a diverse range of ACEs can impact health outcomes in adulthood and far beyond from life-course perspectives 6 , 7 . Studies increasingly establish evidence that ACEs leads to develop mental health issues, including depression, substance misuse, and suicide 8 , 9 , 10 , 11 . A World Health Organization (WHO) study revealed that ACEs were associated with all lifetime DSM–IV disorders worldwide 12 . These associations are explained by both neurobiological development and external factors 13 . For example, early life exposure to chronic stress causes greater activation of the hypothalamic-pituitary-adrena (HPA) axis, and high levels of inflammation, resulting in deficits of cognitive and affective functioning and increased allostatic load 14 , 15 . ACEs also lead to impaired social functioning, such as lack of social support 16 , 17 , 18 .

ACEs traditionally included childhood maltreatment and household dysfunction. For example, physical neglect, characterized by a caregiver's failure to provide for a child's basic physical needs. Recently, the concept has been expanded to include community-level and social factors, such as school bullying and economic hardship 19 , 20 , 21 , 22 , 23 . Furthermore, ACEs can differ by race, culture, and era 19 , 22 . An ACE scale for the Japanese context (ACE-J) has been developed to assess expanded ACEs reflecting the Japanese situation 7 and its potential benefit of use is to capture the influence of expanded and culturally familiar ACEs on outcomes. For example, Japan has a high prevalence of both school bullying victimization and natural disasters compared to other countries 24 , 25 . Childhood poverty is also considered an important factor as a root cause of ACEs from life-course perspective 26 . Although the relationship between the conventional ACEs and mental health issues in adulthood have been well investigated, the more recent potential constructs of ACEs should be further explored 27 .

Few studies have examined long-term effects of a wide range of ACEs in Asians. In Japan, the association of conventional ACEs with mental health was last reported in 2011 28 . A scoping review about different types of ACEs from articles (n = 1281) showed that less articles reported expanded ACEs (e.g., household financial hardship; 18%, victimization by peers; 10%, exposure to natural disasters; 2%) 23 . Besides, over 60% of the articles related to ACEs published from United States 23 . This disproportionate evidence motivates researchers to examine long-term impact mental health by expanded ACEs in various countries. The understanding of its association in ethnic groups of a particular culture can lead to the development and implementation of locally sensitive countermeasures 29 . Moreover, empirical evidence about the association of the expanded concept of ACEs on mental health would benefit specifically to evaluate the impacts of each ACE.

The aim of this study was thus to examine the association of expanded ACEs with mental health in adulthood in Japanese community sample. The impact of childhood poverty and school bullying on mental health was investigated, considering demographic indicators.

Research design

For this research, we utilized data from the Japan COVID-19 and Society Internet Survey (JACSIS), an ongoing nationwide online cohort study conducted in Japan 30 . JACSIS cohort study began in August 2020. The JACSIS included community-dwelling individuals aged 15–79 years. The baseline sample of JACSIS was collected in 2020, consisting of 28,000 participants. In 2022, a follow-up survey was conducted for the participants from 2020 survey or 2021 survey, and new participants were also invited. This resulted in a total of 32,000 participants in the 2022 survey. This study employed a cross-sectional design using the JACSIS 2022 data, which was collected in September 2022.

Participant recruitment

To recruit participants, we utilized email messages to request survey participation from a research panel maintained by Rakuten Insight, Inc. This private company have information about over 2.2 million individuals aged 15 to 79 years with diverse sociodemographic backgrounds, representing the national population across all 47 prefectures of Japan. We employed a simple random sampling method based on sex, age, and prefecture category in accordance with the official Japanese demographic composition as of October 1, 2019, to select potential participants. Those who agreed to participate were provided access to a designated website. Participants had the option to skip questions or discontinue the survey at any point.

Data quality management

To ensure the validity of the data, we excluded respondents who exhibited discrepancies or provided artificial/unnatural responses. Specifically, we used three question items to identify such responses: "Please choose the second from the bottom," "choosing positive in all of a set of questions for using drugs," and "choosing positive in all of a set of questions for having chronic diseases." A total of 3,370 respondents were found to have provided such responses and were subsequently excluded from the study.

Participants

Our study included community-dwelling individuals in Japan who were over 18 years old and had complete data. Participants who were under 18 years old were excluded (n = 13).

Measurement variables

Expanded adverse childhood experiences.

We assessed Adverse Childhood Experiences (ACEs) using the Adverse Childhood Experiences Japanese version (ACE-J) questionnaire 7 . The ACE-J questionnaire was developed to measure individuals' exposure to various adversities during their childhood in Japan. For example, incarcerated household member was excluded, reflecting Japanese culture. Each category of adversity was represented by a single item, except for parental loss, which included both parental death and divorce or separation. In addition to the CDC-Kaiser ACE questionnaire 1 , the ACE-J included, childhood poverty, overcontrol, school bullying, hospitalization due to chronic disease, and exposure to life-threatening natural disasters. The ACE-J questionnaire consisted of a total of 15 items (parental death, parental divorce, mental illness in the household, substance abuse in the household, mother treated violently, physical abuse, physical neglect, emotional abuse, emotional neglect, childhood poverty, overcontrol [“I always felt suffocated because my parents did not respect my opinion”], school bullying, sexual abuse, hospitalization due to chronic disease, natural disaster), and participants were asked whether they had experienced each adversity before the age of 18. The response options were "Yes" or "No." One item related to emotional neglect was a reversed question, specifically assessing whether participants felt loved by their parents. To calculate the total number of ACEs experienced, the score of the reversed item was reversed, and the summed score of all ACE items was used. The ACE-J questionnaire was not validated in publication.

Psychological distress

Psychological distress refers to a broad range of emotional and psychological symptoms or experiences that can cause discomfort, suffering, or impairment in daily functioning.　Psychological distress was measured by The Kessler Psychological Distress Scale (K6), which has been widely used and is preferred for screening for any DSM-IV mood or anxiety disorder. K6 includes six items that measure the frequency of psychological distress symptoms experienced by participants over the past 30 days 31 . Participants provide responses on a scale ranging from 0 (none of the time) to 4 (all the time). Previous studies have reported satisfactory internal reliability and validity for Japanese version of K6, showing that performance in areas under receiver operating characteristic curves (AUCs) was 0.94 detecting DSM-IV mood and anxiety disorders 32 . K6 scores over 13 are regarded as a serious mental distress 31 , 33 , 34 . Prevalence of people with over 13 scores of K6 was reported 4% in Japan 35 .

Demographic characteristics

The sociodemographic characteristics of the participants were assessed, including age, sex, educational attainment (categorized as less than high school, vocational/college, undergraduate, graduate or over), marital status (categorized as married, single/divorced), household income (categorized as < 3 million yen, 3–5 million yen, 5–8 million yen, 8–10 million yen, over 10 million yen, or no response/unknown), and working status (categorized as paid work, no paid work, or students).

Statistical analyses

First, the descriptive statistics were estimated. These included the prevalence of ACEs and severe psychological distress and the coexistence of the ACEs. To address a potential sampling bias due to the internet survey, a propensity score for participation in the internet survey was calculated. We utilized a demographic distribution of a national paper-based survey, the Comprehensive Survey of Living Conditions of People on Health and Welfare (CSLCPHW). Using sex and age group stratifications (sex × age groups = 14 strata), we calculated the propensity score separately for each stratum. The mean of the score was group-mean centered and was set to 1.0 within each stratum. Residential area, marital status, education, home-ownership (household), self-rated health and smoking status, which were available both CSLCPHW and JACSIS, were used for the model to calculate the propensity scores. The inversed propensity score was used as the sampling weight for the calculation of the prevalence of the ACEs and psychological distress. The difference in the prevalence of ACEs among stratified categories (sex and age groups) was tested using a chi-square test. Also, the summed number of ACEs was tested using a t-test in sex and one-way analysis of variance (ANOVA) in age category. The coexistence of the ACEs was presented as a matrix.

For the main analysis, the associations of ACEs with severe psychological distress were assessed by using logistic regression analysis, adjusted by age, sex, marital status household income, work, and educational attainment. The sampling bias was also adjusted by the inversed propensity score. Additionally, the subgroup analyses were conducted stratified by sex and age categories. The statistical significance for all analyses in this study is set at 0.05 (two-tailed), and 95% CIs were calculated. SPSS 28.0 (IBM Corp., Armonk, NY, USA) Japanese version was used.

Ethics approval and consent to participate

The study was reviewed and approved by the Research Ethics Committee of Graduate School of Medicine/Faculty of Medicine, The University of Tokyo (no. 2020336NI-(3)) and by the Research Ethics Committee of the Osaka International Cancer Institute (no. 20084). All methods were carried out in accordance with the Declaration of Helsinki.

Informed consent

Online informed consent was obtained from all participants with full disclosure and explanation of the purpose and procedures of this study. The panelists had the option to not respond to any part of the questionnaire and the option to discontinue participation in the survey at any point.

A total of 28,617 community dwelling people was included in the analysis. The participants’ characteristics are presented in Table 1 . The mean age was 48 years old (standard deviation [SD] = 17.1). Majority demographics included those who were married (62%), with undergraduate level of educational attainment (46%), and with paid work (65%).

The sample weighted prevalence of expanded ACEs is presented in Table 2 . The overall prevalence of expanded ACEs was varied from lowest (physical neglect = 3.2%) to highest (emotional neglect = 38.5%). The mean of summed number of ACEs was 1.75 (SD = 1.94). The histogram of the summed number of ACEs is presented in Supplementary Fig.  1 . The prevalence of those with ACEs over 4 was 14.7%. The prevalence of childhood poverty and school bullying was 26.3% and 20.8%, respectively.

For sexual difference, the mean of the summed number of ACEs was larger for females (1.85 vs 1.65; p < 0.001). Sexual abuse was particularly experienced more in female populations (6.9% vs 1.8%). For age difference, the mean of the summed number of ACEs was highest in age 35–49 years old (1.87 [SD 2.03]). Those over 65 years old showed lowest score of ACEs (1.55 [SD 1.73]). Among those over 65 years old, the prevalence of parental death (21%) and childhood poverty (40%) were higher than other age category (p < 0.001), and parental divorce (7%) was lower (p < 0.001).

Table 3 shows the prevalence of severe psychological distress (K6 ≥ 13), which was adjusted for weighed scores. The overall prevalence was 10.4%. The prevalence of severe psychological distress increased as the number of ACEs increased. The highest prevalence of high distress was observed in those with ACEs over 4 in ages 18–34 years old (40.7%). In the group with the same number of ACEs, younger groups showed significantly high prevalence of severe distress compared to older groups (p < 0.001). The significant group difference of sex was not shown in the group with 2 or more ACEs.

The result of the associations of ACEs with severe psychological distress is presented in Table 4 , using a logistic regression analysis. Almost all individual ACEs, except parental death, were significantly associated with high distress in adulthood in adjusted model (odds ratio ranging from 1.23 to 4.01). The adjusted odds ratio of school bullying, hospitalization due to chronic disease, and natural disaster was 3.04, 2.67, and 2.66; respectively. The odds of high distress increased as the number of ACEs increased; those with ACEs over 4 showed adjusted OR = 8.18 [95% CI: 7.14–9.38].

The result of logistic regression analysis which was stratified by sex and age category is shown in Table 5 . Adjusted odds ratio was rather higher in male than female in physical neglect and sexual abuse (aOR = 4.68 [3.68–5.94], aOR = 4.05 [3.06–5.36]; respectively). In age category, physical abuse and physical neglect were highly impacted on the prevalence of high distress among those over 65 years old (aOR = 5.60 [2.87–10.93], aOR = 6.27 [3.41–11.55]; respectively), compared to other age group. However, parental death, parental divorce, and childhood poverty showed lower odds among those over 65 years old and 50–64 years old, compare to 18–34 years old and 35–49 years old.

Supplementary table 1 shows the relationship between ACEs, which was adjusted for weighted scores. We found high comorbidity of ACEs; for example, those who experienced physical abuse also experienced emotional abuse (75%), overcontrol (68%), and emotional neglect (65%).

This study presented the high prevalence of expanded ACEs in Japan and its strong impact on mental health in adulthood. The mean of summed number of ACEs as measured by expanded ACEs scoring customized for Japanese people was 1.75. The prevalence of those with ACEs over 4 was 14.7% and they significantly showed high odds on severe psychological distress in adulthood, compared to those with none ACE (aOR = 8.18 [95% CI 7.14–9.38]). Childhood poverty showed lower odds among those over 65 years old and 50–64 years old compared to other ACEs. Bullying relatively showed higher odds among all age categories, with some difference of prevalence across age category.

About 75% of participants had one or more ACEs in this study. Reports of worldwide prevalence of ACEs are lower, including 62% in U.S. 36 and 47% in Europe 37 , by measuring 11 items of ACEs in both studies. A systematic review of a ACE-related study with a large sample reported that a pooled prevalence of individuals with one ACE was 23.5% in Europe and 23.4% in North America, and those with two or more was 18.7% in Europe and 35.0% in North America 38 . However, in expanded ACE study (The Philadelphia Urban ACE Study), a prevalence of 83.2% had at least one ACE and 37.3% experienced four or more ACEs, measured by 14 items with additional stresses including bullying 39 . These studies support our findings of prevalence of expanded ACEs.

Among 15 of the expanded ACEs, emotional neglect, childhood poverty, and bullying showed highest prevalence (39%, 26%, and 21%, respectively). A previous study from 2002–2004 using Japanese data reported that parental death (12%), parental divorce (11%), family violence (10%), and physical abuse (8%) were the most prevalent, but neglect was reported less (2%) 28 . The prevalence of emotional neglect in this present study (26%) may be over reported. When compared to recent studies, the prevalence of psychological neglect was 11.6% 40 . One possible reason was that emotional neglect in our study was measured by an inverse item (i.e., “I felt loved by my parents.”). Reversed items in surveys sometimes cause measurement problems due to misresponses 41 . Since this data was obtained online, the misresponse or careless answer may be more likely to occur compared to in-person interviews. However, based on the finding that there is a significant positive association between the presence of emotional neglect and severe psychological distress, it is possible that emotional neglect is this prevalent in Japan. Possible factors contributing to a high prevalence of emotional neglect might include Japan's traditionally reserved emotional culture (e.g., less expression of positive feelings 42 ), insufficient emotional support due to parental employment and household issues, as well as inadequate systems for early detection and protection, potentially resulting in an elevated prevalence rate. The expected level of “loved” for Japanese may be higher than the standard family relationship.

All 15 of the individual ACEs showed the negative impact on mental health, after adjusting covariates. Physical neglect and physical abuse showed highly negative associations (aOR = 4.01, 3.65; respectively). This result was partially consistent with the previous Japanese WHO survey data, which showed parental mental illness and physical abuse strongly affected the onset of mood disorder 28 . With a few exceptions 43 , few paper suggested that physical neglect had a significant impact on mental health; but we should note that those with physical neglect has high comorbidity of ACEs (e.g., childhood poverty, emotional abuse/neglect) in this study. Many studies suggested that emotional abuse and neglect had great impacts on mental health 44 , 45 , 46 , 47 . Such comorbidity might strengthen the impact of physical neglect. Consistent with Tzouvara and colleagues (2023), this study demonstrated that all ACEs can negatively impact mental health, and ACEs can manifest differently in different populations 27 .

In this study, school bullying impacted on deteriorated mental health in adulthood among all age categories, although the prevalence of experience was lower in older generations. School bullying have serious and lasting negative impacts on mental health, including depression 48 , 49 , 50 , 51 , anxiety 48 , 50 , 51 , 52 , 53 , post traumatic stress disorder (PTSD) 54 , and risk of suicide 51 , 52 . Japan has a higher prevalence of school bullying compared to most other countries (i.e., Japan 22% vs OECD countries 19%) 55 . This study showed that the prevalence was low in elderly population. The possible reasons for this low prevalence may less awareness, different school dynamics (societal norms), and supportive community functions in old Japanese 56 . A previous study indicated the widely varied exposure to bullying across countries 57 , even in one country, the prevalence may vary from generation to generation. To reduce the prevalence, evidence-based practice is needed to be implemented at school 58 .

Natural disasters as one of ACEs was overall experienced 3.5% and impacted on severe psychological distress in adulthood, except those 65 or older. The findings were in line with the previous studies, demonstrating that when experiencing natural disaster, such as earthquake, heavy rain/snowfall, flood, heatwaves, storm, and/or tsunami, can cause short-term and long-term deterioration in mental health 59 , 60 , 61 , 62 . The worldwide climate is rapidly changing and we face the increased risk of natural disaster. Assessing the psychological impact that the experience of natural disaster(s) causes may become increasingly important in the near future, in addition to the effort to avoid children from being exposed such traumatic events.

Childhood poverty was experienced more in older age (40% in 65 or older; 17% in 18–34-year-old group), but the negative impact on mental health was less among the elderly population. This result was in line with a previous study showing that accumulative exposure of the economic hardship impacted mental health, but that negative association was attenuated if they experienced upwards mobility 63 . Many of elderly population in this study experienced childhood poverty, but financial difficulty might not persist and change positively. Even so, we should not ignore the importance of childhood poverty for mental health in adulthood, as significant effects have also been found in older adults. A possible mechanism of the link between childhood poverty and mental health are presented; persistent poverty-related challenging tasks 64 , disengagement coping strategy 65 , diminished spatial short-term memory, and helplessness behaviors 66 . Poverty is not only one of the critical social determinants of health 67 , but also an adversity that should primarily be addressed during childhood, when it has significant implications for neurodevelopment, social development, and behavior. The findings of the present study posed the need to ensure that poverty does not persist among the young generation, who suffered economically in childhood.

Overall, this study showed the cumulative negative impacts of expanded ACEs on psychological distress in Japanese adults, as well as individual adversities. A previous study suggested that a 10% reduction in ACE prevalence could equate to annual savings of 3 million DALYs or $105 billion 38 . Primary prevention, or preventing children from having ACEs is urgent action for public mental health. In addition, childhood maltreatment has consistently been shown to be associated with poor treatment outcome after psycho- or pharmaco-therapy in depression 68 . Trauma-informed care can be one of the important approaches to be implemented for tertiary prevention.

Limitations

This study has several limitations. First, generalizability of the findings was limited because this was an online cohort study. Although we adopted sample weighting to adjust the bias and examined the prevalence with large number of participants, we should note that the present result may possibly be different from the real data of community dwelling people in Japan. Participants of online survey have access to the internet and motivation to answer the questionnaire with small reward. It is possible that participants with certain demographic characteristics and traits are likely to participate. Second, a recall bias in terms of measuring ACEs was not avoided. Older participants answered less ACEs may underestimate the impact. Third, the definition of school bullying may also vary between younger and older generations. The authors should note that the outcome of this study was obtained self-report questionnaire and it could cause self-reporting bias. Fourth, there are possibly unconsidered/unmeasured confounding factors. Many factors which can impact on mental health during or after COVID-19 have been presented, but not all factors can be comprehensively considered in the analytic model of this study. Fifth, the number of respondents excluded from the analysis due to inappropriate answer was relatively high. It may be possible that this procedure exclude participants with certain response tendencies. Sixth, although K6 has been shown the relationship with clinical outcome and diagnosis, further study which utilize other clinical assessment may need to be conducted in the future. Seventh, the specific age of having adversity is not clear in this study, although the timing may be important in some ACEs. Future research is needed to consider such detailed information and to examine precise mechanism of the associations of ACEs on health.

Research, policy, and practical implications

Prospective longitudinal study with information about expanded ACEs and clinical diagnosis of mental health disease may be beneficial to suggest the exact impact of ACEs on mental health. Specifically, it is essential to further investigate modifiable childhood factors within the home and school environments to develop effective prevention measures for ACEs through public health policies.

Data availability

The data used in this study are not available in a public repository because they contain personally identifiable or potentially sensitive patient information. Based on the regulations for ethical guidelines in Japan, the Research Ethics Committee of the Osaka International Cancer Institute has imposed restrictions on the dissemination of the data collected in this study. All data enquiries should be addressed to the person responsible for data management, Dr. Takahiro Tabuchi, at the following e-mail address: [email protected].

Felitti, V. J. et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. Am. J. Prev. Med. 14 (4), 245–258 (1998).

Article   CAS   PubMed   Google Scholar  

Hughes, K. et al. The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health 2 (8), e356–e366 (2017).

Article   PubMed   Google Scholar  

Petruccelli, K., Davis, J. & Berman, T. Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis. Child Abuse Negl. 97 , 104127 (2019).

Anda, R. F. et al. The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. Eur. Arch. Psychiatry Clin. Neurosci. 256 , 174–186 (2006).

Bellis, M. A. et al. Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: a national survey. J. Public Health 37 (3), 445–454 (2015).

Article   CAS   Google Scholar  

Shanahan, M. J. Pathways to adulthood in changing societies: Variability and mechanisms in life course perspective. Annu. Rev. Sociol. 26 (1), 667–692 (2000).

Article   MathSciNet   Google Scholar  

Fujiwara, T. Impact of adverse childhood experience on physical and mental health: A life-course epidemiology perspective. Psychiatry Clin. Neurosci. 76 (11), 544–551 (2022).

Fuller-Thomson, E., Baird, S. L., Dhrodia, R. & Brennenstuhl, S. The association between adverse childhood experiences (ACEs) and suicide attempts in a population-based study. Child Care Health Dev. 42 (5), 725–734 (2016).

Leza, L., Siria, S., López-Goñi, J. J. & Fernández-Montalvo, J. Adverse childhood experiences (ACEs) and substance use disorder (SUD): A scoping review. Drug Alcohol Depend. 221 , 108563 (2021).

Merrick, M. T. et al. Unpacking the impact of adverse childhood experiences on adult mental health. Child Abuse Neglect 69 , 10–19 (2017).

Article   PubMed   PubMed Central   Google Scholar  

Liu, M. et al. Adverse childhood experiences and related outcomes among adults experiencing homelessness: A systematic review and meta-analysis. Lancet Public Health 6 (11), e836–e847 (2021).

Kessler, R. C. et al. Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. Br. J. Psychiatry 197 (5), 378–385 (2010).

Meyer, H. C. & Lee, F. S. Translating developmental neuroscience to understand risk for psychiatric disorders. Am. J. Psychiatry 180 (8), 540–547 (2023).

Danese, A. & McEwen, B. S. Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiol. Behav. 106 (1), 29–39 (2012).

Pechtel, P. & Pizzagalli, D. A. Effects of early life stress on cognitive and affective function: An integrated review of human literature. Psychopharmacology 214 , 55–70 (2011).

Sheikh, M. A. The potential protective effect of friendship on the association between childhood adversity and psychological distress in adulthood: A retrospective, preliminary, three-wave population-based study. J. Affective Disord. 226 , 21–27 (2018).

Article   Google Scholar  

Forster, M., Grigsby, T. J., Gower, A. L., Mehus, C. J. & McMorris, B. J. The role of social support in the association between childhood adversity and adolescent self-injury and suicide: Findings from a Statewide sample of high school students. J. Youth Adolescence 49 (6), 1195–1208 (2020).

Weber Ku, E. B. et al. Natural mentoring relationships among survivors of caregiver childhood abuse: findings from the Add Health Study. Ann. N. Y. Acad. Sci. 1483 (1), 50–66 (2021).

Article   ADS   PubMed   Google Scholar  

Cronholm, P. F. et al. Adverse childhood experiences: Expanding the concept of adversity. Am. J. Prevent. Med. 49 (3), 354–361 (2015).

Wade, R. Jr., Shea, J. A., Rubin, D. & Wood, J. Adverse childhood experiences of low-income urban youth. Pediatrics 134 (1), e13–e20 (2014).

MacLochlainn, J., Mallett, J., Kirby, K. & McFadden, P. Stressful events and adolescent psychopathology: A person-centred approach to expanding adverse childhood experience categories. J. Child Adolescent Trauma 15 (2), 327–340 (2022).

Finkelhor, D., Shattuck, A., Turner, H. & Hamby, S. Improving the adverse childhood experiences study scale. JAMA Pediatr. 167 (1), 70–75 (2013).

Karatekin, C. et al. Adverse childhood experiences: A scoping review of measures and methods. Child. Youth Serv. Rev. 136 , 106425 (2022).

Fujiwara, T. et al. Clinically significant behavior problems among young children 2 years after the Great East Japan Earthquake. PLoS ONE 9 (10), e109342 (2014).

Article   ADS   PubMed   PubMed Central   Google Scholar  

Tan, M. & Mao, P. Type and dose-response effect of adverse childhood experiences in predicting depression: A systematic review and meta-analysis. Child Abuse Neglect 139 , 106091 (2023).

Ben-Shlomo, Y. & Kuh, D. A Life Course Approach to Chronic Disease Epidemiology: Conceptual Models, Empirical Challenges and Interdisciplinary Perspectives 285–293 (Oxford University Press, Oxford, 2002).

Google Scholar  

Tzouvara, V. et al. Adverse childhood experiences, mental health, and social functioning: A scoping review of the literature. Child Abuse Neglect 139 , 106092 (2023).

Fujiwara, T., Kawakami, N. & Group, W. M. H. J. S. Association of childhood adversities with the first onset of mental disorders in Japan: results from the World Mental Health Japan, 2002–2004. J. Psychiatric Res. 45 (4), 481–487 (2011).

Goldstein, E., Topitzes, J., Miller-Cribbs, J. & Brown, R. L. Influence of race/ethnicity and income on the link between adverse childhood experiences and child flourishing. Pediatric Res. 89 (7), 1861–1869 (2021).

Miyawaki, A., Tabuchi, T., Tomata, Y. & Tsugawa, Y. Association between participation in the government subsidy programme for domestic travel and symptoms indicative of COVID-19 infection in Japan: cross-sectional study. BMJ open. 11 (4), e049069 (2021).

Kessler, R. C. et al. Screening for serious mental illness in the general population. Arch. Gen. Psychiatry 60 (2), 184–189 (2003).

Furukawa, T. A. et al. The performance of the Japanese version of the K6 and K10 in the World Mental Health Survey Japan. Int. J. Methods Psychiatric Res. 17 (3), 152–158 (2008).

Prochaska, J. J., Sung, H. Y., Max, W., Shi, Y. & Ong, M. Validity study of the K6 scale as a measure of moderate mental distress based on mental health treatment need and utilization. Int. J. Methods Psychiatric Res. 21 (2), 88–97 (2012).

Sakurai, K., Nishi, A., Kondo, K., Yanagida, K. & Kawakami, N. Screening performance of K6/K10 and other screening instruments for mood and anxiety disorders in Japan. Psychiatry Clin. Neurosci. 65 (5), 434–441 (2011).

Nishi, D., Susukida, R., Usuda, K., Mojtabai, R. & Yamanouchi, Y. Trends in the prevalence of psychological distress and the use of mental health services from 2007 to 2016 in Japan. J. Affect. Disord. 239 , 208–213 (2018).

Merrick, M. T., Ford, D. C., Ports, K. A. & Guinn, A. S. Prevalence of adverse childhood experiences from the 2011–2014 behavioral risk factor surveillance system in 23 states. JAMA Pediatrics 172 (11), 1038–1044 (2018).

Bellis, M. A., Lowey, H., Leckenby, N., Hughes, K. & Harrison, D. Adverse childhood experiences: Retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. J. Public Health 36 (1), 81–91 (2013).

Bellis, M. A. et al. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: A systematic review and meta-analysis. Lancet Public Health 4 , e517–e528 (2019).

Merritt, M., Cronholm, P., Davis, M., Dempsey, S., Fein, J., Kuykendall S, et al. Findings from the Philadelphia urban ACE survey 2013. Available from: https://www.rwjf.org/en/library/research/2013/09/findings-from-the-philadelphia-urban-ace-survey.html .

Amemiya, A., Fujiwara, T., Murayama, H., Tani, Y. & Kondo, K. Adverse childhood experiences and higher-level functional limitations among older Japanese people: Results From the JAGES Study. J. Gerontol. Ser. A 73 (2), 261–266 (2017).

Weijters, B. & Baumgartner, H. Misresponse to reversed and negated items in surveys: A review. J. Market. Res. 49 (5), 737–747 (2012).

Iwata, N., Roberts, C. R. & Kawakami, N. Japan-U.S. comparison of responses to depression scale items among adult workers. Psychiatry Res. 58 (3), 237–245 (1995).

Negriff, S. ACEs are not equal: Examining the relative impact of household dysfunction versus childhood maltreatment on mental health in adolescence. Soc. Sci. Med. 245 , 112696 (2020).

Gu, W. et al. Impact of adverse childhood experiences on the symptom severity of different mental disorders: A cross-diagnostic study. Gen. Psychiatry 35 (2), e100741 (2022).

Humphreys, K. L. et al. Child maltreatment and depression: A meta-analysis of studies using the Childhood Trauma Questionnaire. Child Abuse Neglect 102 , 104361 (2020).

van Duin, L. et al. The role of adverse childhood experiences and mental health care use in psychological dysfunction of male multi-problem young adults. Eur. Child Adolescent Psychiatry 28 (8), 1065–1078 (2019).

Peng, C. et al. Specific effects of five subtypes of childhood maltreatment on suicide behaviours in Chinese adolescents: The moderating effect of sex and residence. Epidemiol. Psychiatric Sci. 32 , e45 (2023).

McKay, M. T. et al. A revised and extended systematic review and meta-analysis of the relationship between childhood adversity and adult psychiatric disorder. J. Psychiatric Res. 156 , 268–283 (2022).

Moore, S. E. et al. Adolescent peer aggression and its association with mental health and substance use in an Australian cohort. J. Adolescence 37 (1), 11–21 (2014).

Jadambaa, A. et al. The contribution of bullying victimisation to the burden of anxiety and depressive disorders in Australia. Epidemiol. Psychiatr. Sci. 29 , e54 (2019).

Takizawa, R., Maughan, B. & Arseneault, L. Adult health outcomes of childhood bullying victimization: Evidence from a five-decade longitudinal British birth cohort. Am. J. Psychiatry 171 (7), 777–784 (2014).

Copeland, W. E., Wolke, D., Angold, A. & Costello, E. J. Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence. JAMA Psychiatry 70 (4), 419–426 (2013).

Stapinski, L. A. et al. Peer victimization during adolescence and risk for anxiety disorders in adulthood: a prospective cohort study. Depression Anxiety 31 (7), 574–582 (2014).

Nielsen, M. B., Tangen, T., Idsoe, T., Matthiesen, S. B. & Magerøy, N. Post-traumatic stress disorder as a consequence of bullying at work and at school. A literature review and meta-analysis. Aggress. Violent Behav. 21 , 17–24 (2015).

OECD. Programme for International Student Assessment (PISA) Results from PISA 2015 Students’ Well-Being. 2017 [Available from: https://www.oecd.org/pisa/PISA2015-Students-Well-being-Country-note-Japan.pdf .

Treml, J. N. Bullying as a social malady in contemporary Japan. Int. Soc. Work 44 (1), 107–117 (2001).

Craig, W. et al. A cross-national profile of bullying and victimization among adolescents in 40 countries. Int. J. Public Health 54 (2), 216–224 (2009).

Farrington David, P. & Ttofi, M. M. Reducing school bullying: Evidence-based implications for policy. Crime Just. 38 , 281–345 (2009).

Liu, J. et al. Is there an association between hot weather and poor mental health outcomes? A systematic review and meta-analysis. Environ. Int. 153 , 106533 (2021).

Romanello, M. et al. The 2022 report of the Lancet Countdown on health and climate change: Health at the mercy of fossil fuels. Lancet 400 (10363), 1619–1654 (2022).

Novia, K., Hariyanti, T. & Yuliatun, L. The impact of natural disaster on mental health of victims lives: Systematic review. Int. J. Sci. Soc. 2 (3), 65–85 (2020).

Makwana, N. Disaster and its impact on mental health: A narrative review. J. Family Med. Primary Care 8 (10), 3090–3095 (2019).

Morrissey, K. & Kinderman, P. The impact of childhood socioeconomic status on depression and anxiety in adult life: Testing the accumulation, critical period and social mobility hypotheses. SSM Popul. Health 11 , 100576 (2020).

Hao, Y., De France, K. & Evans, G. W. Persistence on challenging tasks mediates the relationship between childhood poverty and mental health problems. Int. J. Behav. Dev. 46 (6), 562–567 (2022).

Kim, P., Neuendorf, C., Bianco, H. & Evans, G. W. Exposure to childhood poverty and mental health symptomatology in adolescence: A role of coping strategies. Stress Health 32 (5), 494–502 (2016).

Evans, G. W. Childhood poverty and adult psychological well-being. Proc. Natl. Acad. Sci. 113 (52), 14949–14952 (2016).

Article   ADS   CAS   PubMed   PubMed Central   Google Scholar  

Marmot, M. The health gap: the challenge of an unequal world. Lancet 386 (10011), 2442–2444 (2015).

Lippard, E. T. C. & Nemeroff, C. B. The devastating clinical consequences of child abuse and neglect: Increased disease vulnerability and poor treatment response in mood disorders. Am. J. Psychiatry 180 (8), 548–564 (2023).

Download references

Acknowledgements

We thank all study respondents and lab members for their sincere support.

This work was funded by the Japan Society for the Promotion of Science (JSPS) KAKENHI Grants [Grant Number 17H03589;19K10671;19K10446;18H03107; 18H03062;20H00040; 21H04856; 21H03203], the JSPS Grant-in-Aid for Young Scientists [Grant Number 19K19439], Research Support Program to Apply the Wisdom of the University to tackle COVID-19 Related Emergency Problems, University of Tsukuba, and a Health Labour Sciences Research Grant [Grant Number 19FA1005;19FG2001;22FA2001; 22FA1010].

Author information

Authors and affiliations.

Department of Mental Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan

Natsu Sasaki & Daisuke Nishi

Department of Public Health, Kitasato University School of Medicine, Sagamihara, Japan

Kazuhiro Watanabe

Department of Psychiatric Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

Yoshiaki Kanamori

Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan

Takahiro Tabuchi

The Tokyo Foundation for Policy Research, Tokyo, Japan

Department of Public Health, Tokyo Medical and Dental University, Tokyo, Japan

Takeo Fujiwara

You can also search for this author in PubMed   Google Scholar

Contributions

Author D.N. was in charge of this study, supervising the process, and providing his expert opinion on the subject. Authors N.S., T.T., and D.N. organized the study design. The questionnaire was created through discussions with collaborators outside of this work. N.S. analyzed the data. N.S. wrote the first draft of the manuscript, and T.T., T.F., Y.K., and K.W. revised the manuscript critically. K.W. and Y.K. supported the data analysis. All authors approved the final version of the manuscript. The sponsors played no role in the design of the study; in collecting the data or managing the study; in data analysis; in the interpretation of the data; in the preparation, review, or approval of the manuscript; or in the decision to submit the manuscript for publication.

Corresponding author

Correspondence to Daisuke Nishi .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary figure 1., supplementary table 1., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Sasaki, N., Watanabe, K., Kanamori, Y. et al. Effects of expanded adverse childhood experiences including school bullying, childhood poverty, and natural disasters on mental health in adulthood. Sci Rep 14 , 12015 (2024). https://doi.org/10.1038/s41598-024-62634-7

Download citation

Received : 17 October 2023

Accepted : 20 May 2024

Published : 26 May 2024

DOI : https://doi.org/10.1038/s41598-024-62634-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Maltreatment
• Life-course
• Public health

By submitting a comment you agree to abide by our Terms and Community Guidelines . If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

A .gov website belongs to an official government organization in the United States.

A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

• About Adverse Childhood Experiences
• Risk and Protective Factors
• Program: Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action
• Adverse childhood experiences can have long-term impacts on health, opportunity and well-being.
• Adverse childhood experiences are common and some groups experience them more than others.

What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

• Experiencing violence, abuse, or neglect.
• Witnessing violence in the home or community.
• Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

• Substance use problems.
• Mental health problems.
• Instability due to parental separation.
• Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

• Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:999-1005. DOI: http://dx.doi.org/10.15585/mmwr.mm6844e1 .
• Cain KS, Meyer SC, Cummer E, Patel KK, Casacchia NJ, Montez K, Palakshappa D, Brown CL. Association of Food Insecurity with Mental Health Outcomes in Parents and Children. Science Direct. 2022; 22:7; 1105-1114. DOI: https://doi.org/10.1016/j.acap.2022.04.010 .
• Smith-Grant J, Kilmer G, Brener N, Robin L, Underwood M. Risk Behaviors and Experiences Among Youth Experiencing Homelessness—Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts. Journal of Community Health. 2022; 47: 324-333.
• Experiencing discrimination: Early Childhood Adversity, Toxic Stress, and the Impacts of Racism on the Foundations of Health | Annual Review of Public Health https://doi.org/10.1146/annurev-publhealth-090419-101940 .
• Sedlak A, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4): Report to Congress. Executive Summary. Washington, DC: U.S. Department of Health an Human Services, Administration for Children and Families.; 2010.
• Font S, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions. Child Abuse Negl. 2016;51:390-399.
• Swedo EA, Aslam MV, Dahlberg LL, et al. Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020. MMWR Morb Mortal Wkly Rep 2023;72:707–715. DOI: http://dx.doi.org/10.15585/mmwr.mm7226a2 .
• Bellis, MA, et al. Life Course Health Consequences and Associated Annual Costs of Adverse Childhood Experiences Across Europe and North America: A Systematic Review and Meta-Analysis. Lancet Public Health 2019.
• Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students — Adolescent Behaviors and Experiences Survey, United States, January–June 2021 | MMWR
• Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics. 2004 Feb;113(2):320-7.
• Miller ES, Fleming O, Ekpe EE, Grobman WA, Heard-Garris N. Association Between Adverse Childhood Experiences and Adverse Pregnancy Outcomes. Obstetrics & Gynecology . 2021;138(5):770-776. https://doi.org/10.1097/AOG.0000000000004570 .
• Sulaiman S, Premji SS, Tavangar F, et al. Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review. Matern Child Health J . 2021;25(10):1581-1594. https://doi.org/10.1007/s10995-021-03176-6 .
• Ciciolla L, Shreffler KM, Tiemeyer S. Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization. Journal of Pediatric Psychology . 2021;46(7):801-813. https://doi.org/10.1093/jpepsy/jsab027 .
• Mersky JP, Lee CP. Adverse childhood experiences and poor birth outcomes in a diverse, low-income sample. BMC pregnancy and childbirth. 2019;19(1). https://doi.org/10.1186/s12884-019-2560-8 .
• Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. No youth left behind to human trafficking: Exploring profiles of risk. American journal of orthopsychiatry. 2019;89(6):704.
• Diamond-Welch B, Kosloski AE. Adverse childhood experiences and propensity to participate in the commercialized sex market. Child Abuse & Neglect. 2020 Jun 1;104:104468.
• Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663
• Narayan AJ, Kalstabakken AW, Labella MH, Nerenberg LS, Monn AR, Masten AS. Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction. Am J Orthopsych. 2017;87(1):3. https://doi.org/10.1037/ort0000133 .
• Schofield TJ, Donnellan MB, Merrick MT, Ports KA, Klevens J, Leeb R. Intergenerational continuity in adverse childhood experiences and rural community environments. Am J Public Health. 2018;108(9):1148-1152. https://doi.org/10.2105/AJPH.2018.304598 .
• Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):S32-38. https://doi.org/10.1016/j.jadohealth.2013.05.004 .

Adverse Childhood Experiences (ACEs)

ACEs can have a tremendous impact on lifelong health and opportunity. CDC works to understand ACEs and prevent them.